Stirling Road Medical Centre

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 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.
At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to 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 service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.
The service had made improvements in its systems and processes for assessing and reviewing people’s needs.

Now, reception staff understood the needs of the local community and used digital flags in people’s care records to identify adjustments, such as longer appointments or interpreter support. Clinical staff used templates during health reviews to consider people’s wider health, care and wellbeing needs. Staff could also refer people experiencing social isolation, housing difficulties or other social needs to a social prescriber. A social prescribing link worker helps people access non-medical support in their community, such as advice on housing, finances, employment, social activities, exercise groups or emotional wellbeing support, to improve their health and wellbeing.
The service used population information and digital systems to assess need and plan care. Leaders used information about why people contacted the service and the support they needed to understand demand, identify emerging trends and determine the clinical skills required and the differences across sites. Recall systems were used to identify people eligible for NHS Health Checks, with monthly recalls and uptake monitored through governance arrangements. Staff promoted checks opportunistically and leaders reviewed clinical audits, Quality and Outcomes Framework performance (QOF which measures the quality of care provided by GP practices), disease registers, cervical screening, immunisation uptake and long-term condition monitoring through dashboards and governance systems.
The service had strengthened oversight of clinical review actions through weekly reconciliation, dashboards and named leads for long-term conditions.

However, our remote clinical searches found gaps in the identification and follow-up of people who may have a potential missed diagnosis of diabetes. We identified 27 people with a raised HbA1c (a blood test result, which monitors blood sugar levels) and of 5 records reviewed, 2 showed a missed diagnosis and 1 person had not completed a requested repeat test. The service responded by contacting the people identified and ensured follow-up action had taken place.
 

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.
The service had made improvements in its systems and processes for delivering evidence-based care and treatment since the last inspection. Staff had access to current clinical guidance, and national institute for clinical excellence (NICE) guidance was reflected in the service’s policies, procedures and clinical templates. A clinical audit policy set out arrangements for using audit to monitor and improve care. Clinical meetings were used to review NICE updates, medicine safety alerts, audit findings and learning from clinical cases.

The service undertook clinical audits to monitor and improve the quality of care. These included audits of long-term condition management, prescribing and medicines optimisation. Audits included repeat cycles, and leaders used the findings to review clinical practice and monitor improvements. Prescribing data was benchmarked, and outcomes and actions from antibiotic and controlled drug prescribing audits were recorded.

As part of our assessment, a GP specialist advisor undertook remote clinical searches. These found no evidence of excessive benzodiazepine (medicines commonly used to treat anxiety and sleep problems) prescribing. Prescribing levels were consistent with local and national prescribing data which provided assurance that the service supported safe and evidence-based prescribing.
 

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.
The service established referral pathways to other services, and staff we spoke with understood it. The service had embedded multidisciplinary team working. We reviewed palliative care multidisciplinary team (MDT) meeting minutes which demonstrated regular collaborative working between the service and community teams, including the local hospice.
Discussions with MDTs included symptom management, anticipatory medicines, treatment escalation plans, advance care planning, safeguarding concerns and coordination of care. Records demonstrated that actions were clearly identified and followed up, helping to ensure people received coordinated and timely care. Leaders also used these forums to identify and escalate access issues affecting people receiving palliative care and to monitor any impact on service capacity.
The service also demonstrated wider multidisciplinary review through its governance arrangements. Clinical Review Group meetings included discussion of deaths, safeguarding concerns, medicines safety, complaints, incidents and care navigation learning. This supported shared learning across teams and promoted continuous review of care delivery.
 

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.
The service demonstrated a proactive approach to supporting people to live healthier lives through prevention, health promotion, social prescribing and targeted work with local communities. People could access a social prescribing service and physiotherapists. The service also took part in a community initiative in Plymouth, designed to create sustainable access to volunteering, training, and upskilling opportunities. This project utilised community workers and social prescribing approaches to support local population needs. The service carried out NHS Health Checks and uptake was monitored through governance processes.
The service identified and supported carers and monitored this through regular audit activity. A carers register audit showed 4,628 carers had been identified, representing 14% of the service population. Leaders demonstrated a proactive approach to carer identification through online consultation systems, long-term condition reviews, patient surveys and direct outreach. The service maintained oversight of the carers register and had plans to continue improving data quality and support available to carers.
The service had identified and supported specific population groups. Leaders described their work as a Deep End Practice, a programme supporting GP practices serving communities experiencing high levels of deprivation, recognising the needs of a diverse and deprived population. The service operated as a Veterans Friendly Practice, a scheme recognising GP practices that support the health and wellbeing needs of military veterans and had identified approximately 490 veterans. Dedicated appointment availability, links with veteran community services, a veteran’s hub and charity organisations provided additional support tailored to this population group. The service also described arrangements to support homeless people and traveller communities through its Safe Surgery approach which aims to improve access to GP services for people who may face barriers to registration and flexible access

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 service monitored people’s care and treatment through audit activity and governance meetings. Long-term condition audits included re-audit cycles, and outcomes relating to deaths, incidents, complaints, safeguarding, cancer diagnoses, medicines safety and quality improvement were regularly reviewed.
Audit findings and resulting action plans were monitored through the service’s assurance arrangements, enabling leaders to review progress, completed actions and evidence of improvement.
The service monitored uptake of national screening and immunisation programmes. Childhood immunisation uptake was in line with national expectations.
The service monitored cervical screening uptake and recognised areas where performance could be improved. Screening uptake was 66.7% among eligible people aged 25 to 49 years and 69.9% among those aged 50 to 64 years, which was below the national target of 80%. Leaders reviewed performance data and were undertaking quality improvement activity to increase uptake. Planned changes to flu vaccination delivery were intended to improve vaccination uptake and create additional capacity for long-term condition reviews.
Our remote clinical searches identified gaps in diabetes monitoring. Of 5 records reviewed for people whose latest HbA1c (blood test monitoring of sugar levels) was above 75, 4 did not have appropriate or planned follow-up completed. The service took action in response, including adding people to recall processes, arranging repeat tests and GP review, and using the findings to support implementation of an HbA1c pathology management standard operating procedure.
However, our searches found that monitoring for people with stage 4 or 5 chronic kidney disease and those prescribed thyroxine took place.
 

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.
Staff understood and applied legislation and guidance relating to consent and decision-making. The service had consent and Mental Capacity Act 2005 policies to support staff in delivering care and treatment in line with legal requirements. A chaperone policy was also available to support people’s privacy, dignity and choice during consultations. Staff demonstrated awareness of Gillick competency principles and how these should be applied when assessing the capacity of children and young people under 18 years of age to make decisions about their care and treatment.

The service had arrangements to support advance care planning. We reviewed a sample of 5 Treatment Escalation Plans (TEPs) and found that records demonstrated that staff considered and recorded people’s preferences, including where they wished to remain at home or avoid hospital admission and documented DNACPR decisions where appropriate.[