Partners in Health

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We assessed all quality statements in the effective key question.

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

Staff actively involved patients in decisions about their care and treatment, offering appropriate advice and support. Care was regularly reviewed, and staff worked collaboratively with other services to ensure individual needs were met. Assessments considered patients’ communication, personal, and health requirements, with care delivered in line with current evidence and best practice. Partnership working with external agencies supported positive outcomes and smooth transitions between services. Patients were supported to understand their treatment and provide informed consent. Where individuals lacked capacity, staff involved those important to them in decisions made in their best interests.

This service scored 83 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or tailored adjustments. Staff checked people’s health, care, and well-being needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and well-being.

The needs of carers of people using services were also assessed and met. This supported their health and well-being in their carer roles and helped them to provide safe and effective care to the people they support.

To ensure patients had their needs assessed and had effective and optimised health outcomes, the service used a birth month recall system to assess needs and prioritise those at greatest risk of deterioration.

The service implemented a range of initiatives to support effective assessment and management of respiratory conditions. Respiratory nurses shared tutorial videos and visual guides on the use of inhalers and specifically for young people on the correct use of spacers. They practiced “teach back” method to confirm understanding and ensure correct use of inhalers. Patients prescribed Anti-Inflammatory Reliever (AIR) therapy were given personalised peak flow diaries printed with patient details to minimise errors. Within the PCN, a respiratory MDT led by the service lead nurse and a consultant, met regularly to discuss patients with exacerbated asthma, including steroid use and hospital admissions. In addition, a respiratory hotline clinic, staffed by a duty respiratory consultant, allowed the service to seek timely advice, reducing unnecessary hospital admissions. These initiatives resulted in an award for high quality patient care from the Association of Respiratory Nurse Specialists.

As part of our assessment a number of clinical record searches were undertaken by a CQC GP specialist advisor. Of the 5 records reviewed the searches identified that some patients were not followed up by a GPs within 48 hours of steroid use or discharge to review. Following the inspection these patients were contacted and invited for a review. In addition, a new process was implemented whereby a task was added to the duty doctor screen to contact the patient. Twice weekly searches were run to identify missed patients. For example, the use of a red, amber, green rating (RAG) was used for patients at risk and were discussed at MDT meetings. Consultants shared scan results with nurses and staff, enabling informed discussions with patients and providing high-level clinical support. Appointments at a specialised clinic, run by the clinical pharmacist were available for patients at risk of heart failure. Patients were monitored and their condition managed with the support of a GP. The PCN also offered smoking cessation, acupuncture, and anxiety support services.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. Our review of the clinical record system indicated that patients received care, treatment and support that was evidence-based and in line with good practice standards. The management of patients living with long term conditions was good and our searches did not identify any significant gaps in the monitoring of patients.

There were systems to ensure staff were up to date with evidence-based guidance and legislation. For example, monthly clinical meetings included updates on any changes of guidance or recent significant event investigations; safeguarding meetings where updates from the ICB joint meetings were discussed, in addition to safeguarding concerns. Clinical staff provided examples of when new national Hormone Replacement Therapy guidelines and management of childhood asthma was discussed to ensure service staff were updated in the delivery of evidence-based care. There was an internal message system to update all staff on recent changes or important information.

The service worked well across both sites, different teams and other health services to support patients and their families including carers. They shared assessments of patients’ needs when they moved between different services, so people only needed to tell their story once. This aligned to the service vision of a caring and collaborative team, to provide equity of care for all. Staff feedback supported the vision of working closely with other services to provide high-quality joined up care.

Staff described a positive working environment valuing strong team dynamics and the support of colleagues. They appreciated the collaborative nature of their roles and felt well supported by GPs and the leadership team, who were described as visible, approachable, and responsive. Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support.

The service had recently relaunched its Patient Participation Group (PPG) and received applications from interested patients. To support its success and sustainability, the service had a plan to introduce a Terms of Reference and a structured engagement covering key areas such as appointment access and GP patient survey results.

Social Prescribers actively engaged patients through activities such as social groups and craft sessions, and the relationships built through these groups was expected to support the development of a successful PPG.

The service always supported people to manage their health and wellbeing to fully maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support. Staff told us they used every contact with patients to improve the health of the patient population. Staff proactively focused on identifying risks to patients’ health including those receiving palliative care, patients at risk of developing a long-term condition and those with additional needs. Individuals living with long-term conditions were regularly monitored. A GP matrix ensured that relevant blood tests were taken within best practice timeframes and, where appropriate, referred or signposted to local services offering information, education, and tailored support. Staff supported national priorities and initiatives to improve population health, including stopping smoking and weight management initiatives.

We saw good oversight of urgent referrals, with effective systems to ensure patients attended their 2-week wait appointments. Patients at risk of developing Monoclonal Gammopathy of Unknown Significance (MGUD- monoclonal gammopathy of undetermined significance, is a non-cancerous blood condition where bone marrow plasma cells produce an abnormal protein) were reviewed every 3 to 6 months. Those who failed to attend appointments or who were difficult to contact were identified by quarterly audit reports and followed up by staff.

Staff adopted a holistic and person-centred approach to care, which included the use of social prescribing. Patients were offered individual sessions to explore what mattered most to their health and wellbeing. These sessions enabled patients to access a wide range of support, including community initiatives, Cognitive Behavioural Therapy (CBT) and acupuncture, as well as assistance with housing, benefits, financial matters, employment, and education. The staff we talked to were aware of the benefits of social prescribing and effectively signposted patients for support, in addition to their clinical needs. A weekly MDT meeting took place, attended by GPs, Mental Health nurses, care coordinators and social prescribers where referrals and complex cases were discussed to improve clinical management. We saw case studies that showed measurable patient outcomes that influenced clinical resources and treatment pathways.

The social prescribers facilitated safe and supportive environments where patients and their families were encouraged to share experiences, access information, and benefit from peer support. For example, a Parkinson’s Support Group, the first of its kind in Gloucestershire, was established to support people diagnosed with Parkinsons disease and a monthly Dementia Support Meeting was held, to provide companionship, practical advice, and emotional support to those affected by dementia. We saw case studies in which measurable impact to patient lives was demonstrated, including improved health outcomes and access to secondary care services. These improvements were supported by patient-reported outcome measures, showing enhanced quality of life, greater confidence in self-care, and improved satisfaction with services.

A 2-cycle audit was conducted into the management of non-specific back pain, in line with NICE (National Institute for Health and Care Excellence) clinical guidelines. This resulted in the implementation of a new assessment tool used in clinical consultations that highlighted the risks associated with chronic back pain. In addition to promote physiotherapy through access to a Musculoskeletal digital application that helps patients manage musculoskeletal issues through self-guided physiotherapy exercises, education, and progress tracking.

These initiatives influenced health and wellbeing outcomes and delivered preventative primary care.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people.

National data showed that all 5 indicators for childhood immunisations had achieved the 90% minimum uptake rate. Children who were not brought to appointments were followed up with contact made with their parent or carer. Latest national data (dated 30 June 2024) showed that 73% of eligible people had received cervical screening within a set timeframe, compared to the national target of 80%. To promote cervical screening uptake and improve health outcomes, the service collaborated with other community providers to ensure patients with additional health needs, such as those living with Human Immunodeficiency Virus (HIV) were offered annual cervical screening.

The service took part in quality improvement work to improve outcomes for patients and carried out regular clinical audits. For example, in prescribing practices for ADHD (Attention-Deficit/Hyperactivity Disorder, a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, or impulsivity that negatively impact daily functioning) and HRT, and SSRIs (Selective Serotonin Reuptake Inhibitor used to treat depression). We saw 2 cycle audits on the management of non-specific back pain, suicide prevention, anti-coagulation (blood thinning medicines) in atrial fibrillation and patients with diabetes and chronic respiratory conditions. These audits were discussed at the clinical governance team meetings, reflected upon and shared for wider quality improvement measures.

The service told people and, where appropriate, carers and their families about their rights around consent and respected these when delivering person-centred care and treatment.

Staff we spoke with demonstrated the importance of ensuring that people understood the care and treatment offered before obtaining consent. Clinical and non-clinical staff had undergone training in the MCA 2005 and clinical staff understood the requirements of legislation and guidance when considering consent and decision making.

We reviewed a sample of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions and evidenced they were maintained in line with relevant legislation.