The Potteries

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

People were involved in assessment of their needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving between services. Staff made sure people understood their care and treatment to enable them to give informed consent. There was evidence of regular planned follow up for patients, providing continuity of care. There were timely referrals made to appropriate services supporting early detection and intervention

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 service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

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

At this inspection we looked at medical records for several patient groups, including those being prescribed medicines requiring regular monitoring and those being prescribed high-risk medicines. We found that the practice was able to evidence that patients were receiving treatment and/or monitoring in line with national guidelines.

The service 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.

A designated health inequalities champion lead on targeted work to address areas of low uptake ensuring services reach patients who may be at higher risk or less likely to engage

The service worked well across teams and services to support people.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 actively monitored all referrals to ensure timely appointment scheduling, including referrals made through the urgent suspected cancer pathway. The medical secretary carried out regular checks to confirm that patients referred for suspected cancer had been allocated a hospital appointment. We saw evidence where the practice staff worked jointly with learning disability nursing team and secondary care providers to remove barriers to access by providing coordinated support and minimising the risk of nonattendance.

The practice had established links with palliative nursing teams and hospice services. We saw examples where patients transitioned between services seamlessly, improving patient experience and reducing fragmentation of care.

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. The practice worked with other services to ensure continuity of care and held regular multi-disciplinary team (MDT) meetings. For example, we saw evidence where patients with end of life needs were supported by the paramedic and palliative care clinical lead at the practice for a comprehensive assessment providing continuous and consistent clinical oversight.

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

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.

The practice met national targets for screening and immunisations. From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in standards and evidence-based clinical guidance.

The practice had conducted a two-cycle antibiotic prescribing audit with the second audit cycle showing clear improvement in adherence to guidance, with more accurate antibiotic selection, dose and duration. The practice introduced a text message patient information system to provide patients with written information regarding antibiotic risks, safety advice and expected outcomes. The audit demonstrated that consistent use of prescribing resources strengthened antimicrobial stewardship across the practice.

The service told people about their rights around consent and respected these rights when delivering person-centred care and treatment. Staff understood the requirements of legislation and guidance when considering consent and decision making.

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