Blake House 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 assessed all quality statements in the effective key question. At our last assessment we rated this key question as requires improvement. At this inspection the rating remains the same.

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support.

The service did not always make sure people’s care and treatment was effective because they did not always monitor people’s health needs. However, the service made appropriate considerations about whether people had capacity to make decisions, and they involved relevant people to help make decisions in the best interests of a patient where necessary. The service worked well across teams and services to support people and ensure key information about people was available to professionals who needed to review it.

This service scored 58 (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 did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

A CQC GP Specialist Advisor (SpA) completed a series of remote clinical searches which identified a lack of monitoring of people with long-term conditions. The service was not recognising alerts to medication reviews or when a review was due. For example, reviews of medication, particularly for people who can experience an exacerbation of symptoms, were not being completed in line with national best practice guidance and recorded.

Our GP SpA saw there were 22 people alerting as overdue monitoring in the frail or over 75 group. This group is vulnerable and require a review every 4 months for repeat blood tests, weight check and to check liver functions. However, of the 5 patient records we reviewed these were not completed. The service told us these are done annually, however, we saw one person had not received a review in 2 years.

There were issues with coding on people’s care records. This meant peoples care records did not contain up to date information relating to a diagnosis or potential diagnosis.

However, feedback we received from people using the service was positive. People felt involved in assessment of their needs and felt confident staff understood their individual and cultural needs.

Reception staff were aware of the needs of the local community. Reception staff 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.

The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

Findings from our remote clinical searches indicated not all people received care in line with guidance.

The service did not have policies in place to ensure staff are up to date with legislation, evidence based good practice and required standards.

The service did not always act on medicine safety alerts. For example, the Medicines and Healthcare Products Regulatory Agency (MHRA) released an alert on 23 September 2020 stating the importance of collecting information to reduce the possibility of an overdose.

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 worked with others to ensure continuity of care, including where clinical tasks were delegated to other services.

The service involved all staff in meetings. There were standing agenda items which are discussed at every team meeting. The service used this space to encourage staff to contribute innovative ideas to create new ways of working. Staff told us they feel comfortable raising concerns and ideas in this space. The service held meetings that involve the community and the service’s patient participation group (PPG). The minutes from these were shared with staff highlighting updates and changes.

The service utilised a real-time digital care management system to ensure accurate, up-to-date care plans across all NHS services.

Leaders and staff worked with the local PCN to meet the needs of its population. Regular multidisciplinary meetings took place so when people received care from a range of different staff, teams or services, this was co-ordinated.

Staff told us they felt communication within the service was very good.

The service supported people to manage their health and wellbeing, so people could always maximise their independence, choice and control.

Staff were aware of community services and were able to signpost people to such services.

There was a learning disability register which was maintained by the service.

Annual checks take place for people identified as having a learning disability or autistic people.

Training is available to staff which includes sepsis and recognition of a deteriorating patient. However, not all staff had completed this training.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Our remote clinical searches identified the service did not always utilise systems in place to monitor people’s health and wellbeing.

The service did not operate a system of clinical audits to improve outcomes, and there was no oversight of monitoring ongoing improvement in the delivery of effective care. We asked the service for examples of audits it had completed recently, however, none were provided as part of this inspection Based on published data from March 2024, 68% of eligible people aged 25 to 49 and 73% aged 50 to 64 had received cervical screening. This was below the national target of 80% uptake. This data also showed the service had not met the World Health Organization’s (WHO) minimum uptake target of 95% for childhood immunisations.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff had completed training in the Mental Capacity Act. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were noted to have been made appropriately and made in line with relevant legislation. We saw evidence appropriate discussions had been held with people and/or their carer about DNACPR decisions. The mental capacity of people was considered. Multidisciplinary approaches to decision making were made where necessary.