Musters 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

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same. This meant people’s outcomes were good, and people’s feedback confirmed this.

We looked for evidence that staff involved people in decisions about their care and treatment and provided them with advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

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 healthcare, wellbeing, and communication needs with them.

Reception staff were aware of the needs of the local community. Digital flags within the care records system were used to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present.

Feedback from people using the service was mostly positive. People felt involved in assessments of their needs and felt confident that staff understood their individual needs. Staff had a good knowledge of the local community. During our assessment we invited people to provide feedback directly to us. Six people provided feedback regarding the service. People informed us that “the nurse took time to listen to me” and “the doctors and nurses were very helpful.”

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

All staff had completed learning disability and autism training, and people with complex health needs were given longer appointments with both a nurse and doctor to review their complex needs. The practice offered a quiet place for people to sit whilst waiting for their appointments who may be anxious to wait in a busy and noisy room.

The provider had systems to identify people with previously undiagnosed conditions. For example, people whose blood tests results showed they had pre-diabetes were offered appointments to advise them how they could prevent it developing into diabetes.

The practice had considered the Accessible Information Standards and made adaptations in line with this. For example, a ramp to the electronic doors at the entrance, a hearing loop and parking for disabled people.

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.

People were involved in decisions about their care, including what was important and mattered to them, for example, end of life care.

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. Staff had access to local and national guidelines which could be accessed easily through online platforms with links to guidance also available through their clinical system. Updates to guidance were shared with all relevant staff at meetings whose minutes were circulated to ensure all staff were aware.

For example, the salaried GP had recently completed an audit, review, and update to the protocol for urine testing which was shared with the practice team.[AM1][SH2] Urine samples are tested at the practice to rule out health conditions or help monitor health conditions. For example, testing urine to ascertain if a service user had a urinary tract infection or testing urine in a service user who had a diagnosis of diabetes to monitor levels of sugar in the urine.

Staff we spoke with told us they held clinics to support people with long term conditions such as asthma, diabetes and chronic heart disease. They told us they used local and national guidelines and kept up to date through training and updates circulated within the practice.

Clinical audits were conducted to ensure care was delivered in line with legislation and recommended guidelines. For example, the practice carried out regular audits of women of childbearing age receiving sodium valproate (a medicine used to treat epilepsy and bipolar disorder which if taken during pregnancy, can cause birth defects). Women identified were contacted and consulted regarding contraception advice or medication changes if they wanted to get pregnant.

In conjunction with their primary care network (PCN), the service instigated a proactive care frailty pilot called “Prevent. Protect. Prioritise Health” to review people over the age of sixty-five who had qualifying factors to indicate that they were severely or very severely frail. A total of 51 severely or very severely frail people across the network were included within the audit, of which forty-one people were identified to require some form of intervention. Intervention included being referred to their usual GP or referred to a Social Prescriber for additional social support. Learning points and actions from the audit review, which were implemented in the practice, included the collection of carers details if these were not known, reviewing frailty severity when people had their influenza vaccine and proactive health checks for people over 75 years. This was also used as an opportunity to have end-of-life discussions and complete advance care planning forms.

The service worked well across teams and services to support people. They shared 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 service worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. People had access to services provided by the primary care network (PCN), including physiotherapy, social prescribers and extended access appointments. Mutual support and learning were shared across the PCN.

Referrals to other services were audited to ensure that appointments were created for people in a timely manner, for example, when people were referred for suspected cancers. The medical secretary regularly checked that people referred to suspected cancer services had received an appointment from the hospital. The practice regularly held multidisciplinary meetings with community nurses, palliative care nurses and specialist nurses, to review vulnerable people’s holistic care and treatment, including people with a cancer diagnosis.

Staff feedback was positive about how they worked together with the service. For example, there was team working across different staff groups to address issues such as follow up of people who failed to attend important appointments. Staff informed us that the team met daily to discuss key priorities. Staff described the culture at the service as “professional, everyone was hardworking and conscientious, compassionate and positive and friendly.” Staff told us that they felt supported and working at the practice was like being in an extended family.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

The service did not meet national targets childhood immunisations. National data collected on 31 March 2024 showed all 5 indicators for childhood immunisations were below the 95% World Health Organisation based target for uptake, but above the 90% minimum uptake expected for these immunisations. There were effective systems in place to follow up people who failed to attend for these appointments. From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. Baby immunisation and smear appointments were arranged around the convenience of service users to encourage attendance with appointments being commenced from 7 o’clock in the morning and were continued throughout the day. To evidence service user satisfaction the service collected feedback from service users who attended early morning appointments. Comments received included; “Made all the difference. Before work I was therefore not worrying all day.” “Early morning appointment meant I didn’t have to miss work. It would be great if this could be a regular service.” “Never attended smear before as full-time carer for son and struggled to find the right time. Was so happy when offered early morning appointment”

National data showed that the targets for cervical cytology screening were 80%. The service almost achieved this target with 79.9%. The service implemented robust systems to invite eligible women, in their preferred method of contact and language. Audible, visual and easy to read formats were provided for people who have a sight, hearing or learning disability. The service utilised interpreters where required and offered flexible appointments for people to include early and late appointments. People who did not respond to smear invitations received a telephone call from the practice nurse and a chase up letter via recorded delivery.

The service carried out regular audits to monitor and improve care as well as participating in their Primary Care Network (PCN) and national audit activities. For example, the service carried out an audit to monitor the frequency and compliance of people who attended a medication review. People who were found to be outside of the six-monthly review period were contacted by the in-house pharmacist, their medication reviews were completed, and they were added on to a regular recall program and were invited to attend the practice on a six-month basis.

In addition, through audit, it was identified that some people were over ordering their inhaler medicine for the treatment of asthma. As a result of the audit, the asthma nurse, in collaboration with the in-house pharmacist, reviewed these people to understand why they were over ordering their medicine. A monthly audit to monitor prescribing of asthma medicine was implemented to check compliance and ensure that people were treated safely and that their symptoms were well controlled. The GP felt that the practice had implemented an excellent system to support these people and keep them safe. For example, The National Institute for Health and Care Excellence (NICE), recommends that service users with asthma who have had an exacerbation of their asthma are reviewed within forty-eight hours of the exacerbation. We reviewed five service users with an asthma diagnosis who had had an exacerbation of their asthma. Four out of the five service users had been reviewed within the relevant time period and one person had been contacted and invited for a review, however, had not participated in a review.

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.

The practice had effective processes for recording consent within the medical record and guidance was accessible on the practice’s website.

The staff had good knowledge of gaining and assessing consent options allowing the delivery of person-centred care and treatment which was in the person’s best interest. This included young people and people who did not have capacity to consent to care and treatment.

The practice kept records of lasting power of attorney and consent to treatment forms were in place where people had mental capacity. We reviewed three records which showed Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.