Church Street 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

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

We rated this key question as Good.

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 National GP Patient Survey found 88% of patients felt their needs were met during their last general practice appointment which was in line with the national average of 90%.

The practice had systems and processes in place to identify patients’ needs and preferences during the registration process. The practice used digital flags within the care records system to highlight any specific individual needs such as the requirement for longer appointments or for a translator to be present. Staff referred patients with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

Staff checked patients’ health, care, and wellbeing needs during health reviews. Clinicians used templates when conducting reviews to support the assessment of patients’ wider health and wellbeing.

We discussed how clinicians identified and monitored patients at risk of developing a long-term condition. Clinicians explained they had systems and pathways established to follow. We undertook clinical record searches to review these systems. Clinical searches identified 25 patients as having a potential missed diagnosis of chronic kidney disease (stage 3-5). We looked in detail at 5 patient records and found no issues with the care and treatment for these patients.

Leaders told us about initiatives they were implementing to reduce health inequalities which included Serious Mental Illness (SMI) annual health checks for patients with schizophrenia, bipolar disorder or psychosis. Staff were working to improve the uptake of SMI health checks by including home visits to undertake these reviews; using practice data to drive targeted reviews; and ensuring reviews encompassed all of core elements. Clinicians explained some patients with SMI routinely missed appointments and so when they did attend, they would do as much as they could do for them in one visit.

There were systems in place to ensure staff were up to date with relevant legislation, evidence-based practice and required standards. Clinical meetings were in place to keep staff up to date. For clinicians who were unable to attend this meeting in person, these meetings were minuted and disseminated to all clinicians.

The remote clinical searches we undertook of the practice’s clinical records system included reviewing the monitoring of people with long-term conditions to assess if National Institute for Health and Care Excellence (NICE) recommendations were followed.

For example, we identified 110 patients with diabetes whose last blood glucose reading was over 75. We reviewed a random sample of 5 patient records and found no issues with the care and treatment of these patients for their diabetes.

As part of our clinical records searches, we reviewed the records of patients prescribed short-acting beta-2 agonist (SABA) inhalers (“reliever" inhalers used for quick relief from asthma symptoms like wheezing and breathlessness): We identified 63 out of 1984 patients on the asthma register had been prescribed 2 or more courses of rescue steroids. We reviewed a sample of 5 patient records and found no issues with the care and treatment of these patients for their asthma.

Our clinical searches also identified patients with chronic kidney disease (Stages 4 or 5) who had not had appropriate urea and electrolyte blood test monitoring in the last 9 months. This search identified 1 patient out of a total of 81 patients diagnosed with chronic kidney disease (Stages 4 or 5). We reviewed this patient’s record and discussed their care with clinicians. We were provided with evidence that the practice had made numerous recall contacts with the patient. As part of our clinical searches related to chronic kidney disease, we identified one patient who had chronic renal failure coded on their clinical record, not chronic kidney disease. We discussed this issue with clinicians and following our inspection they took immediate action to address this issue.

As part of our clinical searches, we reviewed the care of patients with hypothyroidism (underactive thyroid). We identified 574 patients who were diagnosed with hypothyroidism of which 2 had not received thyroid function test monitoring. We looked in detail at these patient records and discussed their care with clinicians. We found 1 patient had been short-scripted their medication; and there was documented refusal of 1 elderly patient to undertake blood tests.

The practice worked well across teams and services to support patients. They made sure patients only needed to tell their story once by sharing their assessment of needs when people moved between different services. Staff had access to information they needed to assess, plan, and deliver patients’ care, treatment, and support. Systems were in place to share information about patients electronically with other services.

The practice worked with other services to ensure continuity of care and engaged in regular multi-disciplinary team (MDT) meetings. For example, the practice held regular cancer and mental health MDT meetings. For patients identified as approaching end of life, the practice referred to and worked closely with, the community palliative care team. Home visits and care packages were implemented to ensure patients’ wishes were followed and carried out in their final stages of life.

The practice worked closely with the Primacy Care Network (PCN) and were the highest referring GP practice in the network to the Work and Health coaches. The PCN team included Work and Health Coaches who supported patients to return to work; the Frailty team who supported patients with frailty, advanced care planning and wellbeing in later life; the Cancer Care team who undertook cancer care reviews for patients and provided both emotional and practical guidance; the Bone Health team who interpreted and reviewed patient scans, provided lifestyle advice and osteoporosis management and education; the Diabetes team who managed complex and poorly controlled diabetic patients; and the Advanced Physiotherapy team who provided assessments for patients with musculoskeletal, pain management and mobility issues.

As part of the Wyre Forest Health Partnership, practices worked together to share learning from incidents and complaints; to identify risks; monitor performance through clinical dashboards; and collaborate with joint initiatives.

The practice supported patients to manage their health and wellbeing to maximise their independence, choice and control. Staff supported national priorities and initiatives to improve population health including stopping smoking and tackling obesity.

The practice waiting area and the practice website provided a wide range of health information for patients.

For weight management, the practice referred patients to the 12-week online NHS ‘Digital Weight Management Programme’ which supports adults living with obesity who also have a diagnosis of diabetes, high blood pressure, or both, to manage their weight and improve their health. In addition, the practice had also arranged Slimming World vouchers for people to attend this slimming group. The practice had also signed up to provide a Local Enhanced Service (LES) to treat patients for chronic weight management. A LES is a tailored NHS primary care service commissioned locally by Integrated Care Boards (ICBs) to meet specific population needs, going beyond core GP contract requirements. The practice also had an Advanced Results Protocol in place which facilitated clinicians identifying pre-diabetes and raised cholesterol.

As part of the Wyre Forest Partnership, the practice engaged in joint health promotion initiatives such as the weekly ‘Walk Talk Walk’ group where patients could meet and go for walks or runs together and talk with each other. This group took place every Tuesday at 6:30pm and met at the rear entrance of Kidderminster Medical Practice.

The practice routinely monitored patients care and treatment to continuously improve it. Staff endeavoured to ensure that outcomes were positive and consistent, and that they met both the clinical expectations and the expectations of patients. Staff focused 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 undertook regular clinical audits which demonstrated quality improvement. One audit related to the clinical coding of patients with atrial fibrillation (a heart rhythm disorder) to ensure medication is prescribed correctly and appropriate monitoring occurs.

As part of our assessment, we reviewed the practice performance data for childhood immunisations. The World Health Organisation (WHO) recommends a rate of 95% for all routine childhood vaccinations.

Published national data showed the percentage of children aged 5 who had received immunisation for measles, mumps and rubella (two doses of MMR) was 96%.

The percentage of children aged 2 who had received immunisation for measles, mumps and rubella (one dose of MMR) was 95%.

The percentage of children aged 2 who had received their booster immunisation Pneumococcal infection was 94%.

The percentage of children aged 2 who have received their immunisation for Haemophilus influenza type b and Meningitis C was 93%.

The percentage of children aged 1 who had completed a primary course of immunisation for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus influenza type b (Hib), and Hepatitis B (Hep B) was 97%.

The practice had an Immunisation Co-ordinator whose role included making contact with families who fail to attend for immunisations to discuss the reasons for this and ascertain if there is anything the practice can do to support them. Staff explained in some cases they have carried out home visits for families for immunisations and GPs have carried out telephone calls with families who were vaccine deniers.

In addition to childhood immunisation data, we reviewed published national data for the uptake of cervical screening. The practice had achieved 78%, which was in line with the national target of 80%. The practice was working to improve the cervical screening uptake and gave us examples of how they were doing this which included providing more appointments for cervical screening at both the start and the end of the day; telephoning patients who had failed to attend their screening appointments; and arranging a practice ‘Pink Party’ to promote cervical screening awareness. Leaders told us for patients who were particularly anxious about cervical screening, they had been booked in with the GP lead for Women’s Health to receive their smear test.

The practice told patients about their rights around consent and respected these when delivering person-centred care and treatment. A consent policy was in place to ensure appropriate consent was obtained from patients when receiving care and treatment. Staff understood the requirements of legislation and guidance when considering consent and decision making.

Patients were offered a chaperone for care and treatment when this was appropriate. Chaperone posters were on display in the practice to inform patients of this service and staff who provided this service had completed chaperone training.