Netherley Health Centre

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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 assessed all quality statements under this key question. This is the first rated assessment of this service since the provider took over the contract. We rated this key question as good.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People who were the most clinically vulnerable were assessed and prioritised using a system of clinical triage.

Support was available for people with additional needs or communication needs. For example, people who required the services of an interpreter or patients who had a learning disability.

Staff shared relevant information with other professionals when planning care and treatment. Patients’ treatment records and prescriptions were updated to reflect any changes needed.

People living with a long-term condition and those with a learning disability were invited for regular review of their health, care and treatment and staff used templates for this to ensure the reviews were appropriately detailed. The provider had effective systems to identify people with potentially undiagnosed conditions, for example diabetes.

A designated member of staff was the lead for supporting patients who were receiving end of life care. Multi-disciplinary meetings were held on a regular basis where the needs of patients with complex conditions or those approaching the end of life could be discussed, reviewed and planned for. The gold standards framework was used to support this. The provider had recognised a need to identify and increase the number of non-cancer patients managed under the gold standards framework. There was also a designated lead nurse to maintain oversight and review of patients living with cardio-vascular disease and heart failure with an emphasis on proactive and preventative care and treatment.

Work was underway to establish a more accurate picture of the prevalence of chronic disease amongst the patient population and a proforma had been introduced to support staff to assess acuity. Call and recall for patients living with long-term conditions had gone to full direct telephone contact to encourage people to attend for checks and follow ups and to prevent digital exclusion. An area of work was underway to improve the planning for review of patients presenting with multiple long-term conditions.

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

Systems were in place to ensure staff were up to date with national guidance, evidence-based good practice and required standards. Staff attended regular meetings, training, educational sessions and underwent regular appraisal.

A programme of clinical audit was in place to assess the care and treatment provided and aimed at improving outcomes for patients. In addition, a range of audits/checks covering clinical aspects of care and treatment were carried out on a regular basis.

The experience of people who used the service as indicated in the national GP Patient Survey showed that 81% of respondents (compared to 92% nationally) stated that during their last appointment they had confidence and trust in the healthcare professional they saw or spoke to. We saw a lot of positive feedback from patients with regards to their experience of care and treatment provided by members of the clinical team in feedback provided in the NHS Friend and Family test.

We looked at the workflow for managing clinical correspondence and tasks and found these were up to date. The service had experienced a level of backlog in the management of clinical letters. This had been addressed through outsourcing the task.

Our review of the clinical record system for the sample of people whose care and treatment we looked at, indicated that people received care, treatment and support that was evidence-based and in line with good practice standards. The results of the clinical searches for the management of patients living with long term conditions were good and did not identify any significant gaps in the monitoring of patients.

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 and provide shared care where relevant.

The provider worked with colleagues in the local primary care network (PCN) to meet the needs of the patient population.

Multi-disciplinary meetings were held on a regular basis so that when people received care from a range of different staff, teams or services, this was co-ordinated.

People who were the most clinically vulnerable were prioritised and the practice worked with other healthcare professionals to deliver coordinated packages of care.

The service supported people to live healthier lives and manage their health and wellbeing. 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 local and national priorities and initiatives to improve population health, including smoking cessation, weight management and encouraging patients to take up national screening programmes.

People living with long term health conditions underwent regular monitoring. They were referred or signposted to local support services for information, education, advice and support linked to their needs. This included referrals for diabetes education, dietary advice and smoking cessation.

The provider encouraged patients to attend for health screening. People who had not attended for cancer screening were followed up and encouraged to attend. However, cancer screening rates remained below target. Childhood immunisation uptake was also lower than average and did not meet the World Health Organisation targets. The provider told us the actions they have put in place to encourage uptake in both of these areas.

Members of the clinical team provided patients with information and support to manage their own health, care and wellbeing where possible. People were also encouraged and supported to make healthier choices to help promote and maintain their health and wellbeing and prevent deterioration.

Our review of the clinical record system indicated that patients received care and treatment that supported them to live healthier lives.

Leaders demonstrated that monitoring and improving outcomes for patients was important to them and they used information and data to drive improvement. The service routinely monitored people’s care and treatment to continuously improve it. People who required monitoring underwent regular checks on their health.

From the clinical records we reviewed, we found that people who used the service experienced positive outcomes in line with best practice guidance.

Clinical and non-clinical audits were carried out to improve outcomes for patients. Where the practice was not performing in line with other services within the locality and nationally actions were in place to address this. For example, to improve the uptake of cancer screening and childhood immunisation amongst the patient group.

Staff understood the importance of ensuring that people knew what they were consenting to and the importance of obtaining consent before they delivered care or treatment.

Staff had undergone training in the Mental Capacity Act. Staff understood the requirements of legislation and guidance when considering consent and decision making. We looked at a sample of ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions in patient records. Appropriately completed documents were available and had been shared with other relevant services and alerts had been added to the patient record system.