Bartley Green Medical 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 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 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 service was positive. People were involved in the 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. They had 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.

The provider had effective systems to identify people with previously undiagnosed conditions. Our clinical searches identified some patients as having a potential missed diagnosis of diabetes. However, after reviewing a sample of five patients we found all were appropriately reviewed and no risk was identified.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. Overall, this was done 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 were viewed demonstrated care was mostly provided in line with current guidance.

Staff were able to give examples of how they maintained up to date knowledge and delivered evidence-based care. For example, the service audited the management of people with respiratory conditions where certain medicines were prescribed. This showed that care had been reviewed and, where needed, was updated, including medication adjustments and opportunistic lifestyle advice to support improved outcomes. However, clinical records we reviewed showed overall staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. As part of our assessment, remote clinical searches conducted by a General Practitioner Specialist Advisor identified a small cohort of patients prescribed a high-risk medicine who required regular monitoring. These were, patients in receipt of disease-modifying anti-rheumatic drugs (DMARDS) used to treat conditions like rheumatoid arthritis who were due a review. There was no evidence of harm and the service responded promptly, by carrying out a risk assessment and putting in place an action plan to ensure the ongoing identification and regular review of these patients.

The service worked well across teams and services 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 services.

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, including where clinical tasks were delegated to other services. The practice had robust processes for submitting and monitoring referrals to other services, such as 2 week wait referrals.

The service supported people to manage their health and wellbeing to 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 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 initiatives to improve population health, including stopping smoking and tackling obesity.

The service supported patients’ health by offering lifestyle advice and NHS health checks opportunistically when they accessed health care.

The service was part of a local exercise initiative for both staff and patients with plans to collaborate with another local practice to build on this.

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. However, at the time of the inspection national data of the service showed the uptake of all childhood immunisations and cervical screening was below the national average. The staff acknowledged this and provided examples of how they addressed barriers to uptake. For example, staff told us the process to identify people who had English as a second language and how they booked interpreters to use in patient appointments.

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 clearly recorded. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms we reviewed showed decisions were appropriate, made in line with relevant legislation and the care plans for these patients were satisfactory.