Island Health

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• 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 reviewed 6 quality statements in the Effective key question – 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 and consent to care and treatment. Patients were regularly assessed, and care and treatment were delivered in line with current legislation and evidence-based guidelines. The service had a programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. Staff worked together and with other organisations to deliver care and treatment.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they were involved in the assessment of their needs and support was provided to maximise their involvement. The national GP patient survey carried out from January to March 2024 had 127 responses. This found 75% of patients stated the healthcare professional was good at listening to them, and 87% of patients stated they were involved as much as they wanted to be in decisions about their care and treatment. In addition, 86% of patients had confidence and trust in the health care professional they saw or spoke to and 91% of patients said their needs were met.

We were provided with patient feedback from local Healthwatch which they had gathered between January 2024 and October 2024. Healthwatch staff interviewed patients in person at the practice and completed a questionnaire. There were 28 responses. The positive feedback included the quality of online consultations (filling out an online form about your symptoms) and the quality of treatment and care received. People were also positive about the attitude of staff at the service. There was negative feedback about people’s experience of getting an appointment and the ease of getting through to the GP practice by phone. The negative comments were regarding delays in getting through on the phone and availability of appointments. CQC did not speak to patients on the days of the assessment.

Leaders explained how patients’ immediate and ongoing needs were fully assessed, and patients’ treatment was regularly reviewed and updated. Leaders and staff told us the service would use a series of codes and alerts on the patient record to highlight people’s communication needs and any impairments. The service had systems and processes in place to identify people’s needs and preferences during the registration process. Staff told us they checked people’s health, care, wellbeing and communication needs during health reviews.

The service had a system in place to ensure people’s assessments were up-to-date and staff understood people’s current needs. As part of the assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. Our record reviews indicated that patients presenting with symptoms which could indicate serious illness were followed up in a timely and appropriate way.

A search identified 15 patients with blood tests indicating they may have an undiagnosed long-term condition. We looked at 5 patient records and found that all patients with this potential undiagnosed long-term condition had been contacted and their records coded with a diagnosis.The clinical searches identified a total of 36 people diagnosed with asthma, who had been prescribed 2 or more courses of rescue steroids in the last 12 months. We reviewed 5 patient records to check if they had been followed up correctly and found all had received follow up within 1 week of prescribing rescue steroids for asthma, and all patients had an adequate assessment documented at the time of prescribing rescue steroids. A search identified 4 patients with CKD Stage 4 or 5 who appeared not to have had necessary monitoring in the last 9 months. Two of these patients had severe kidney damage and were under the care of a specialist transplant team in secondary care. Two patients diagnosed with CKD appeared to be overdue a blood pressure check. We reviewed the records of 2 patients diagnosed with CKD Stage 4 or 5 and found no concerns and that the GP had reviewed these patients. A search identified 106 patients with a complication of diabetes with poorly controlled blood sugar. The service had 676 patients with diabetes. We looked at 5 records and found no concerns. A search identified 2 patients of 318, with underactive thyroid who had not had thyroid function test monitoring for 18 months. We reviewed the patient records and found patients with hypothyroidism were monitored appropriately.

The national GP patient survey carried out from January to March 2024 had 127 responses, 86% of patients had confidence and trust in the health care professional they saw or spoke to and 91% stated their needs were being met. During this assessment we were only able to speak with one patient and they were happy with the care and treatment they received from the service.

Leaders and staff told us the service had systems and processes to keep clinicians up to date with current evidence-based guidelines. Staff had access to the National Institute for Health and Care Excellence guidelines. In addition, staff had protected time to attend training on a Thursday, and also shared learning with other clinicians by instant messaging or at weekly clinical team meetings.

The service delivered people’s care and treatment in line with current national guidance and best practice. Staff discussed patient care at clinical, safeguarding and integrated care team meetings. A review of a sample of patients’ clinical records demonstrated they had received evidence-based care. Staff had completed clinical audits to ensure they were meeting clinical guidelines. The GP partners monitored the service’s clinical performance.

There were effective arrangements in place for working with other health professionals to ensure quality of care for patients. During this assessment we were only able to speak with one patient, who told us clinicians took time to explain things and helped them to understand any health issues they have.

The leaders explained that when people received care from a range of different staff, teams or services, it was coordinated, and staff worked collaboratively to understand and meet the range and complexity of people's needs. Clinicians attended monthly Integrated care meetings to discuss patients with complex needs. Shared care agreements were made with secondary care providers regarding the prescribing and monitoring of patient medication. When a patient was discharged from secondary care into primary care with complex needs the service would review the patients’ needs and carry out a home visit if appropriate.

The staff from local integrated care system stated they did not have any concerns about the service. The service was actively involved in their local primary network, where they led on pilots and worked with other services to improve the local health inequalities.

The service was informed about patients who had attended any emergency services promptly and any follow up was reviewed by the GP. The service had a shared care protocol last reviewed in September 2024, this outlined the role and responsibilities of the patient, the GP and specialist in prescribing medication that would normally be prescribed in secondary/tertiary care. The GP partners were responsible for the overview of specific clinical areas.

The national GP patient survey carried out from January to March 2024 had 127 responses. This found 91% of patients stated their needs had been met. When asked about accessing the service, 49% stated the experience of contacting the service was very or fairly good and 76% knew what the next step would be after contacting the service.

CQC had received 5 complaints in the last 12 months. There were no specific complaints regarding supporting people to live a healthier life but 2 referred to peoples care and treatment and 2 regarding access to appointments. One complaint referred to the process of requesting repeat prescriptions. CQC did not speak to patients on the days of the assessment.

The service had two full-time care coordinators who contacted patients with complex needs or who were vulnerable to ensure their needs were being met. They would refer patients to the social prescriber and welfare and social organisations. Staff told us patients had access to a community mental health specialist nurse and a first contact physiotherapist who both worked weekly at the service. A diabetes specialist nurse also ran a clinic at Island Health for more complex patients with diabetes. Staff told us the service would be starting a hypertension pilot in January 2025 where a community pharmacist would run a hypertension review clinic at the service. The service had been involved in forming its own wellness team, which was made up of health and wellbeing coaches, social prescribers and volunteer coordinators. This had delivered health and wellbeing services, many of which had input from the local community and run by local residents. For example, patients had access to a weekly coffee morning and a weekly walk and talk and fitness classes and monthly menopause support group. There was also a bereavement support group which met monthly. Patients could also join a gardening group at the Martyn Daniels Community Garden for Local Wellness, an outdoor space for patients of GP services on the Isle of Dogs. A GP at Island Health told us they had established a pre-diabetes exercise group. This 6-month fitness programme invited newly diagnosed pre-diabetic people to attend exercise classes.

Staff at the service engaged with the local community through facilitating or taking part in groups and charity events. They had also been involved in the implementation of a mental health coffee morning held quarterly at the service, to help reduce barriers and fear around attending a GP service and talking about mental health.

Posters and leaflets were available to direct patients where to seek further advice. The service had a list of patients who acted as carers for relatives to enable staff to provide extra support. The service nurses carried out phlebotomy to enable patients to have their blood tests in their own homes.One of the GPs had led on developing a Home Health Service. This was a PCN-led service specifically designed to meet the needs of housebound and vulnerable patients, to help patients to stay independent and healthy for as long as possible at home. The home health service was rolled out successfully across all practices in the PCN and the neighbouring PCN. The home health team worked closely with the service wellness team, ensuring that frail, housebound patients and their carers benefited from a range of services tailored to their needs.

We could not collect the evidence to score this evidence category.

Leaders described how they reviewed the uptake of patient monitoring for long term health conditions weekly using computer software. Leaders explained they conducted audits which were linked to areas where they felt quality could be improved. The leaders and staff told us that audits were discussed at clinical team meetings. Leaders told us the service had recently subscribed to Ardens to support EMIS searches for continuous monitoring and improvement.

During this assessment, we found staff had not followed the practice policy on cervical screening failsafe procedures. We were not assured that the failsafe system in place was effective. Staff were not able to show us an audit trail that showed a result was received back by the practice for every smear sample taken. Following our inspection, leaders told us they had an Ardens audit template in place for monitoring the receipt of cervical smear results and that the audit would be run on a regular basis. Leaders submitted evidence following our inspection, that the safety netting audit confirmed that all cervical smear results had been received for the last 3 years. We saw that staff were auditing inadequate smear results received.

The provider submitted clinical and management audits, these covered medicines, health condition monitoring, patient consultations, death reviews and infection prevention and control audits, which they had carried out to improve outcomes for patients. The service carried out EMIS searches for continuous monitoring and improvement. The leaders held weekly clinical team meetings which monitored patients’ outcomes, where the findings were shared with the local integrated care system.

The service submitted clinical audits which covered prescribing safety, medicines and health condition monitoring, which they had carried out to improve outcomes for patients. The provider reviewed the uptake of childhood immunisations and cervical screening. Island Health was located in an area with high levels of vaccine hesitancy among some minority ethnic groups. The service had not met the WHO based national target of 95% for five of the childhood immunisation uptake indicators (01/04/2022 to 31/03/2024). The service was aware of these results and had an action plan to improve uptake. For example, there was a dedicated staff member responsible for reviewing and running the service recall. When a child turned 1 the service sent a birthday card and a reminder to parents to book the one year of age immunisations. The service took part in a new pilot in November 2024,focusing on providing information to people in the community, about childhood immunisation. They provided unverified data from 1 April 2023 to 31 March 2024 to show they had achieved over 80% uptake in two of the childhood immunisations, and 76% in one indicator. The service had not met the national target of 80% uptake for cervical screening (NHS Digital data dated 30/05/2023). The service told us that many patients were from black and minority ethnic groups and for cultural reasons did not want to have a cervical smear; the service identified a high number of Bengali speaking patients who were not attending for a smear test. The service sent a text with a link to a video explaining in Bengali what cervical cancer is and why people should have a test. The service had a recall system and sent texts to patients with information about cervical screening and a self-booking link. Unverified data for cervical screening showed the service had achieved an average uptake of 74% (1 April 2023 to 31 March 2024). Service data cannot be directly compared to the nationally validated data.

We could not collect the evidence to score this evidence category.

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. We saw that consent was documented. Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

The leaders submitted a copy of the consent policy and withdrawal of consent forms policy last reviewed in February 2024. We reviewed five patients Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions and found they were made in line with relevant legislation and were appropriate. Most staff had completed mental capacity act training.