BHF Highgate Surgery

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 assessments of their needs. The service mostly monitored people's care and treatment to continuously improve it although we observed some patients were overdue their medicines reviews and uptake of cervical cytology and childhood immunisations were below recommended standards. Staff reviewed assessments taking account of people’s communication, personal and health 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 services. Staff made sure people understood their care and treatment to enable them to give informed consent.

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.

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. Reception staff were aware of the needs of the local community. Reception staff used digital flags within the clinical records system to highlight any specific individual needs, such as the requirement for longer appointments or for an interpreter to be present. However, our clinical searches identified that staff were not utilising the clinical alerts on the clinical records system so not all tests and actions were synchronised meaning multiple attendances for the patient. The provider told us they would review this. 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 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. 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. However, we did observe during our clinical searches that they were not following recommended guidance with regard to the length of time between blood tests for patients who were pre-diabetic to determine diagnosis of diabetes. The provider was going to discuss this and review their protocol at their next clinical meeting.

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 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.

The service mostly 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, we observed some patients were overdue a review of their medicines and uptake of cervical cytology and childhood immunisations were below recommended standards. Our clinical searches showed some good overall monitoring processes in place for patients on medicines that required regular monitoring. For example, we identified 1 patient with hypothyroidism out of 98 on the register who had not had a monitoring blood test done within 18 months. We saw from the medical records that the practice had tried to contact the patient regarding this. From the clinical notes we reviewed, we found that people who used the service mostly experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. However, the practice was not meeting national targets for cervical cytology screening and childhood immunisations. The most recent data held by CQC for childhood immunisations (April 2023 to March 2024) showed the practice had not met the World Health Organisation (WHO) target of 95% completion in all areas. They had met the 90% target for children aged 1 year and 5 years but was at 85.7% for children aged 2 years. The most recent available data (June 2023 to March 2024) held by CQC for the percentage of persons eligible for cervical cancer screening who were screened adequately within 3.5 years for persons aged 25 to 49, and within 5.5 years for persons aged 50 to 64 showed the practice had achieved 68.8%, the national target being 80%. We discussed this with staff and leaders who told us that they would actively send out text message reminders, letters and phone patients who were overdue or who had missed their appointment. They told us patients could access 2 of the provider’s other practices for cervical cytology to offer more flexibility of appointment times and the nurse would send a link to information for parents regarding the childhood immunisation programme or speak to them if they had concerns.

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 provider used a ReSPECT (recommended summary plan for emergency care and treatment) plan, as did all practices in Barnsley, to record agreed recommendations for a person’s clinical care in future emergencies if they were not able to make the decision, this included do not attempt cardiopulmonary resuscitation (DNACPR) decisions where appropriate. We observed clinical flags were on patients’ records when they had a completed ReSPECT form and plans had been made in line with relevant legislation.