Henmore Health - Brailsford Surgery

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• 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 people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.This is the first assessment of this service since its registration with CQC. This key question has been rated as Good.

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. There were systems in place to highlight any specific individual needs, such as the requirement for longer appointments or for a translator 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.

GPs worked with other professionals to assess people’s needs collaboratively. For example, the GP lead for end of life care carried out joint visits with the palliative care nurses. The needs of people with dementia were jointly assessed by a GP and the care co-ordinator to ensure their social and medical needs were met.

Our remote clinical searches showed that effective systems to identify people with previously undiagnosed conditions were in place. They also showed that people with long-term conditions such as asthma, chronic kidney disease, hypothyroidism and diabetes were appropriately monitored and reviewed.

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.

Clinical records we reviewed demonstrated care was mostly provided in line with current guidance.

The service mostly worked well across teams and services to support people. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. There was evidence of working with the wider health care teams through multi-disciplinary teams (MDT) meetings. Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support.

However, due to a breakdown in the relationship between the practices within the Primary Care Network (PCN), the PCN was no longer in place. Temporary care provision had been put in place for people and long-term solutions were being explored by the provider. This had created anxiety for some people. For example, a care home expressed concerns that the Team Up home visiting service, previously provided by the PCN and highly valued, had stopped. The practice provided this service now and the care home feared they may not understand the needs of the people living in the home. However, they acknowledged they needed to give this time before being able to make an informed judgement. The provider told us they had received positive feedback from the home following the allocation of a named GP who had recently started to deliver this service from the practice.

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, people 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 and tackling obesity. Staff signposted people to initiatives to improve people’s health. For example, Live Well Derbyshire for weight management and smoking cessation. People with a learning disability or autism were offered annual health reviews and extended appointments to meet their needs.

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 uptake for cervical screening for 25-49 year olds was 81% and, 80% for women aged 50 to 64 year olds. These met the national target of 80%. National data showed all 5 indicators for childhood immunisations had achieved the 90% minimum target of which 3 had met the 95% World Health Organisation based target. 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.

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