Clay Cross Medical Centre

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 looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this. This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

This service scored 67 (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 mostly made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber

Our remote clinical searches showed that people with hypothyroidism were monitored effectively.

However, we potentially identified 43 people with a missed diagnosis of chronic kidney disease (CKD) stage 3-5. Of the 5 patient records we reviewed, there was a monitoring issue with 1 person and 2 people had a missed diagnosis of CKD 3.Two days after our assessment, the provider sent us an analysis of the searches which showed that 29 people did have CKD and their records had been updated. Follow up tests or discussions were arranged for the remaining people.

Our remote searches identified 90 people whose diabetes was poorly controlled. We sampled the records of 5 of these people and found that 2 people were overdue a review and the required monitoring. The provider informed us they were in the process of recruiting a practice nurse with a special interest in diabetes to work with the pharmacist to address this.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. This was mostly done in line with legislation and current evidence-based good practice and standards. However, national guidance to follow up for people with asthma who had had 2 or more courses of steroids in last year was not always followed. The provider informed us they would write a policy to put this in place. Systems were in place to ensure staff were up to date with evidence-based guidance and legislation.

The service worked well across teams and services to support people. We received very positive feedback from 2 care homes where the practice provided care and treatment regarding the support they received and the weekly ward rounds. Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care.

There was evidence of working with wider health care teams though multi-disciplinary teams (MDT) meetings. People had access to services provided by the Primary Care Network (PCN), including social prescribers and pharmacy technicians. Support and learning was shared across the PCN. The service had worked with their Patient Participation Group to make improvements to the service.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. It supported people to live healthier lives and where possible, reduce their future needs for care and support. Staff focused on identifying risks to peoples’ health, including those in the last 12 months of their lives, people at risk of developing a long-term condition and those with caring responsibilities. There was a carer's champion to provide additional support.

Staff supported national priorities and initiatives to improve population health by signposting people to initiatives such as tackling obesity and smoking cessation.

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 themselves.

The practice’s cervical screening rate of 78% was just below the national target of 80% and had been consistent over time. There was a recall system in place to follow up people who failed to attend this screening. All of the 5 childhood immunisations targets met the 90% minimum uptake rate.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. A consent policy was in place to ensure appropriate consent was obtained from people when receiving care and treatment.

A do not attempt cardiopulmonary resuscitation (DNACPR) policy was available for staff to refer to. Decisions were appropriate and were made in line with relevant legislation. Representatives from 2 care homes where the provider provided care and treatment told us that DNACPR decisions were reviewed in a timely manner. They told us that people important to them were involved in these decisions when a person did not have the mental capacity to make decisions.