Island City Practice Also known as Lake Road Practice

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 practices to achieve this. This is the first inspection for this practice since its new registration with CQC. This key question has been rated as Good.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. Feedback from people using the practice was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Reception 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 for a translator to be present. Staff checked people’s health, care, and wellbeing needs during health reviews. From our remote clinical searches completed as part of this inspection, evidence showed clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. For example, all patients with a diagnosis of asthma had received the appropriate monitoring. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The practice planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance. For example, people who were at risk of diabetes had been recalled to see the diabetic nurse following blood results in line with national recommendations.

The practice worked well across teams and practices to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different practices. 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 practices to ensure continuity of care, including where clinical tasks were delegated to other practices.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. The practice supported people to live healthier lives and where possible, reduce their future needs for care and support. Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and gave an example where they were working with individual patient’s medication regime and how this can be better controlled. The team had recently commenced a project to support patients who were frequent attendees to hospital or accessing 111 by offering a longer appointment slot to discuss their needs in depth. The outcome of this was to offer patients an opportunity to work closely with the practice and be referred to relevant specialists. There were 60 patients identified, a personalised care and support plan was created and onward referrals made. The practice plans to audit their results in 6 months to see if the calls/visits have reduced. We saw the practice had information boards with posters and leaflets for patients, for example, promoting cervical screening awareness.

The remote clinical searches identified the practice routinely monitored people’s care and treatment to continuously improve it. They ensured outcomes for patients were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. The practice was below the national targets for screening and childhood immunisations and took actions to improve this. For example, with childhood immunisations, the provider had set up a programme to speak to families directly to aim to promote the uptake of childhood immunisations. As part of the remote clinical searches, clinical notes were reviewed, and we found people who used the practice experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. For example, patients with long-term conditions were seen to have detailed notes recorded with relevant and appropriate review information.

The practice 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 clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.