Ravenscroft 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.

This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Score: 2

The service did not always make sure people’s care and treatment was effective because they did not routinely check and discuss people’s health, care, wellbeing and communication needs with them. Staff had not followed prescribing protocols and guidance to ensure monitoring was up-to-date and people’s care needs were routinely reviewed.

As part of the assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. A sample of the records of patients with long-term health conditions were checked to ensure the required monitoring was taking place. These searches were visible to the practice.

Gaps in the safe and effective monitoring of patients with long term conditions and medication reviews were identified during the clinical searches, in addition to the practices recall processes and management of historical alerts. The provider acknowledged the concerns raised during the recent inspection and took them seriously. Since our assessment, the provider has informed us of changes they had made following the assessment. For example, the practice told us that all patients who do not attend their appointment now receive a phone call from reception, and the appointment is re-booked. GPs were asked to use a diary recall template to ensure that if patients had not come in for a review or repeated their investigations, this would be identified so the practice could contact the patients to be recalled for an appointment. In addition, systems for managing long-term conditions had been strengthened and reviewed, and the practice prescribing policy amended to ensure that if patients are due a review or tests, a message is sent to the patient to book an appointment, their prescription quantity reduced and systems to further safely reduced medicines implemented. The practice had strengthened recall processes to ensure patients who do not respond to messages and phone calls received a follow up letter to their address. If there is still no contact, further actions would be identified to manage the practice patient list effectively and safely.

Score: 2

The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. Staff told us they had access to up-to-date evidence-based guidance and legislation. However, clinical records we saw demonstrated care was not always provided in line with current guidance. For example, information had not been placed on patient records to ensure that it was safe to continue to prescribe and that the patient received timely care and treatment. Gaps were identified in protocols which set out the process, or action to be taken if patients did not respond to appointment invites or failed to attend appointments.

Since this assessment, leaders had responded to our feedback about individual patients and identified learning for the wider clinical team. These changes will be reviewed at the next assessment.

Score: 2

Leaders told us there was effective communication and coordination within their own service to enable staff to plan and deliver people’s care and treatment. However, we found evidence that records were not always coded correctly, with information relating to medicine reviews and diagnosis. This meant that when people moved in between services, there was a risk that their records were not correct or complete.

Leaders told us the practice participated in the local Primary Care Network (PCN), where they collaborated on shared service delivery and quality improvement initiatives.

Score: 3

The service supported people to live healthier lives and where possible, reduce their future needs for care and support. Staff said patients had access to social prescribers, health and wellbeing coaches, mental health specialist nurses, and a local weight loss programme. Posters and leaflets were available to direct patients where to seek further advice. The practice had a list of patients who acted as carers for relatives, to enable staff to support them.

Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

Score: 2

The provider had processes to monitor people’s care and treatment to continuously improve it. However, they did not always ensure outcomes were positive and consistent or met both clinical expectations and the expectations of people themselves. There was a system in place to recall patients for long term health condition reviews. The service had administration leads to follow up patients and ensure continuity. However, processes for reviewing the uptake of patient monitoring for long term health conditions needed strengthening. Results from our clinical searches showed there were shortfalls in monitoring long term conditions. There were also shortfalls with ensuring relevant blood tests had been carried out prior to a review or prescriptions being issued.

The provider reviewed the uptake of childhood immunisations and cervical screening. The service had not met the World Health Organisation (WHO) based national target of 95% for all five of the childhood immunisation uptake indicators (between April 2023 to March 2024 and April 2024 to March 2025). The service had also not met the 90% minimum uptake coverage for five of the five uptake indicators. The service was aware of these results and had informed us of plans to improve uptake. The provider told us that as of April 2025, they had improved across all five targets and had met the expected 95% target for two out of five indicators.

The provider told us they attributed their improved outcomes to the work they had done with their ICB, including piloting a new flip book for childhood immunisations, video recordings in different languages to encourage immunisations and participating in the campaign video to encourage immunisations which was filmed at their practice and included one of the practice nurses. Leaders told us that nurses were proactively calling parents to encourage them to bring their children for their immunisations. During this telephone appointment nurses explained the risks and benefits of ensuring their children’s immunisations were up to date. The practice had also altered their registration process to capture data of immunisations given to children in different countries and encouraged parents to provide this information so that they could keep their records accurately updated.

The service had not met the national target of 80% uptake for cervical screening (NHS England Digital data dated June 2024) achieving 52% and 65% respectively for the two indicators; the number of women aged 25 to 49 years old who have had an adequate screening test within the last 3.5 years as a percentage of the eligible population and the number of women aged 50 to 64 years old who have had an adequate screening test within the last 3.5 years as a percentage of the eligible population.

The provider told us that they had improved across both indicators and as of April 2025 they had achieved 70% and 99% respectively for the two indicators. Leaders told us they had increased cervical screening by increasing the number of nursing sessions and providing their nurses with protected time to contact and encourage patients to attend, as well as offering different appointment times to allow working patients to attend their appointments outside of working hours. They had contacted those patients who had their cervical screening carried out either privately or abroad to provide the results to update their medical records. They had also actively engaged with the local community to promote the importance of cervical screening and at post-natal appointments clinicians encouraged and promoted cervical screening.

Score: 3

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.Staff understood and applied legislation relating to consent. Capacity and consent were recorded. We saw that consent was documented. Staff gave patients information about care and treatment in a way they could understand and offered appropriate support and time to make decisions. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.