Hagley 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.

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

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

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.

We reviewed the practice systems to identify people with previously undiagnosed conditions. Clinical searches identified 9 patients as having a potentially missed diagnosis of diabetes. We looked in detail at 5 patient records and found 4 out of the 5 patients did not have diabetes, and the 1 patient who had been diagnosed with this condition, had been recently diagnosed and had already been invited for an appointment with the practice.

The vast majority of feedback from patients using the service was positive. The National GP Patient Survey found 98% of patients felt their needs were met during their last general practice appointment which was above the national average of 90%.

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 42 patients with diabetes whose last blood glucose reading was over 75. We reviewed a random sample of 5 patient records and found 1 patient was overdue their diabetic medication review, however this patient had already been booked an appointment with the practice.

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 35 out of 1163 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 all 5 had received an adequate assessment at the time of the prescribing of rescue steroid. However, we found there were inconsistencies in the follow up of these patients to check their response to treatment in an appropriate timescale following the acute exacerbation of their asthma. National Institute for Health and Care Excellence (NICE) guidance recommends that patients receive a follow up within 48 hours. We discussed this issue with clinicians who explained they were aware of this issue and had already introduced an alert on the clinical system to prompt staff to book patients in for a follow up appointment.

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 39 patients diagnosed with chronic kidney disease. Our review in detail of this patient’s record found the patient was currently under the care of a renal clinic where they received necessary monitoring for their condition.

As part of our clinical searches, we reviewed the care of patients with hypothyroidism (underactive thyroid). We identified 372 patients who were diagnosed with hypothyroidism of which 3 patients had potentially not received thyroid function test monitoring for 18 months. We looked in detail at the records of these patients and discussed their care with clinicians. We found no issues with the care and treatment of these patients for their hypothyroidism.

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. Staff engaged in regular multi-disciplinary team (MDT) meetings with mental health, frailty, and children and young people teams.

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.

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 such as the weekly walking and running group.

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 cardiovascular disease, clinicians were undertaking a proactive recall project for patients identified at high risk of developing the disease. In addition, clinicians undertook pre-diabetes screening for patients, identifying those at risk; and provided education referrals for patients designed to prevent or manage the condition.

Staff told us they had recently started 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.

As part of the Wyre Forest Partnership, the practice engaged in joint health promotion initiatives such as the weekly ‘Run Talk Run’ 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 also referred people to the ‘Wyre Forest Exercise Referral Scheme’ where patients with long terms health conditions were supported to increase their physical activity levels and enhance their overall health and wellbeing.

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. The practice undertook regular clinical audits, and we were provided with evidence of two-cycle audits which demonstrated quality improvement. 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.

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. We found the practice was meeting all targets for childhood immunisations.

Published national data showed the percentage of children aged 5 who had received immunisation for measles, mumps and rubella (two doses of MMR) was 97%.

The percentage of children aged 2 who had received immunisation for measles, mumps and rubella (one dose of MMR) was 96%.

The percentage of children aged 2 who had received their booster immunisation Pneumococcal infection was 96%.

The percentage of children aged 2 who have received their immunisation for Haemophilus influenza type b and Meningitis C was 97%.

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 99%.

Staff told us the practice had appointed a Care Co-ordinator to engage with parents and patients and increase the uptake of childhood immunisations. In addition, the practice engaged in an outreach vaccination project where targeted home visits were undertaken.

In addition to childhood immunisation data, we reviewed published national data for the uptake of cervical screening. The practice had achieved 78%, which was slightly below the national target of 80%. The practice was working to improve the cervical screening uptake, and staff told us they had appointed a Cancer Care Co-ordinator to lead on following up patients who failed to attend for screening appointments.

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.