Mayflower Medical Practice

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 rated the key question of effective as requires improvement.

The service did not always maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care and wellbeing with them. They did not always plan and deliver evidence-based care and treatment to people who used the service. The service worked well across teams and services to support people. They supported people in managing their health and well-being to maximise their independence, choice and control. The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not monitor through audit the process for seeking consent.

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 always maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care and wellbeing with them.

Assessments were not always up to date to ensure staff fully understood people’s current needs as they were not always routinely reviewed as identified in the CQC clinical searches referred to below. However, we saw examples of ongoing actions the provider had taken to improve the assessment of patients’ needs. For example, GP appointments had been increased to allow GPs to address any outstanding recalls on a patient’s clinical record to ensure the patients’ needs were being fully assessed. This was being closely monitored by the provider to ensure this was happening.

As part of our assessment, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor. The records of patients with long-term conditions were reviewed to ensure the required monitoring was taking place. These searches of the practice’s clinical records system included patients with asthma who had had 2 or more courses of rescue steroids in the last 12 months (excluding patients who have been prescribed regular steroids for other purposes). Another search reviewed the monitoring of patients with chronic kidney disease (CKD): stages 4 and 5. We also looked at the monitoring of patients with hypothyroidism, with a further search involving patients with diabetes whose latest HbA1c was >75mmol/l. We found that not all patients with long-term conditions had the appropriate monitoring and reviews, in line with national guidance, to check their health and medicines needs were being met. Systems to identify these patients and make sure they were offered the appropriate investigations, treatment, and monitoring were not always effective.

852 patients were recorded on the practice asthma register. Of those, 32 patients had been prescribed 2 or more courses of rescue steroids in the last 12 months (excluding patients who have been prescribed regular steroids for other purposes). We looked in detail at 5 patient records and found in most situations there was no follow-up after the use of oral steroids.

385 patients were recorded with chronic kidney disease (CKD): stages 4 and 5. All patients had had the required monitoring in the last 9 months.

253 patients were recorded with hypothyroidism. Of those, 7 had not had the required monitoring. We looked in detail at 5 patient records. 3 of the 4 patients had not responded to recalls by the practice for them to be reviewed. Despite these attempts, 4 patients potentially were not receiving the correct dose of medication.

499 patients were recorded with diabetes. Of those, 70 patients whose latest HbA1c was >75mmol/l was recorded. We looked in detail at 5 patient records and found most patients had satisfactory monitoring. One patient was identified as not having had their diabetes and diabetic medication reviewed since the last HbA1c. After the assessment, the provider provided evidence to show that previous attempts at recalling the patient for review had been unsuccessful.

As part of our series of patient clinical record searches, patients with potentially missed diagnoses of conditions were also reviewed to ensure the required assessments and reviews were taking place. We looked at patients with a potential missed diagnosis of diabetes and found that they were not always followed up appropriately. Systems to identify these patients and make sure they were offered the appropriate investigations, treatment and monitoring were not always effective.

14 patients were identified with a potential missed diagnosis of diabetes. We looked in detail at 5 patient records. We advised the provider to review all 14 patients identified, with a specific plan for 2 patients identified through our search.

During the assessment, feedback was given to the provider concerning patients identified from the clinical searches so that their clinical records could be reviewed and actioned appropriately.

The service did not always plan and deliver evidence-based care and treatment to people who used the service. The practice had systems and processes to ensure that staff were up to date with national legislation, evidence-based good practice and required standards. For example, minutes of clinical meetings showed new NICE guidelines were shared and issues of staff not following guidance were identified and raised. The provider monitored that these guidelines were followed through regular auditing of consultations. Staff made use of clinical system templates to support the management of patient care and treatment. However, findings from our patient clinical record searches indicated that not all patients received care that was in line with national guidance. Examples of these findings have been highlighted in other parts of this report, such as assessing needs under the key question effective and medicines optimisation under the key question safe.

During the assessment, feedback was given to the provider concerning patients identified from the clinical searches so that their clinical records could be reviewed and actioned appropriately.

The service worked well across teams and services to support people. Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. We noted that 94% of the people who responded to the 2024 GP Patient Survey said during their last appointment, the healthcare professional had all the information they needed about the patient. This was in line with local and national averages.

Leaders and staff were working with primary care networks to meet the needs of the patient population. Multi- disciplinary discussions took place regularly so that when people received care from a range of different staff, teams or services, this was co-ordinated.

The service supported people in managing their health and well-being to maximise their independence, choice and control. They demonstrated a commitment to support people to live healthier lives and where possible, reduce their future needs for care and support. As well as supporting national priorities and initiatives to improve population health, including stopping smoking and tackling obesity, multiple other initiatives based around the community and personalised to the patient demographic were in place.

The provider employed a patient experience manager to manage some of these initiatives. Examples include work to identify and improve the identification of carers and engaging with community organisations to better understand the patient demographic. They developed a profile of the ethnic minority population to assess their participation in cervical screening, bowel screening, and childhood immunisations. They hosted pop-up visits from charities such as Age UK and Equipment Loan Services to raise awareness of their services. Minutes of the patient participation group minutes demonstrated that they were continually looking for suggestions for further pop-ups and to offer this regularly. They advertised these in various places including social media platforms.

The needs of carers of people using services were assessed helping to support their health and wellbeing in their carer roles and helping them to provide safe and effective care to the people they supported. A significant amount of work had been undertaken by the provider to improve the identification of carers resulting in an increase of 3% in the last 12 months of informal carers. 429 patients were currently registered as a carer equating to 5.8% of the practice population.

The service did not always routinely monitor people’s care and treatment to continuously improve it. Our patient clinical record search showed people who used the service were not always monitored as set out in legislation, standards, and evidence-based clinical guidance. Despite this, we saw effective approaches to monitor people's care and treatment, and their outcomes were being developed and embedded into practice. Examples included clinical audits and audits of GP consultations were now regularly completed which resulted in improved monitoring arrangements and outcomes for patients and systems to monitor uptake in childhood immunisations and cancer screening programmes.

Patients with a learning disability were offered an annual health check. 22 of the 30 people on the register had received this.

The provider told us that no contract was currently in place in Doncaster for NHS Health checks to be undertaken. They said they expected clinicians to review patients opportunistically when they attended for appointments. We saw evidence of this.

The latest published cervical screening data from 2023 showed 78% of eligible patients registered with the practice had been screened adequately within the recommended period. Performance has been consistent since 2016, falling slightly below or achieving the 80% national target. Unverified data from the provider showed 96% of people aged between 25 and 49, and 97% of people aged between 50 and 64 who were eligible had been screened. The latest published data showed the practice had met national targets for the number of children immunised against various infectious diseases on 4 out of the 5 targets.

Our patient record searches did not demonstrate that consent was always recorded appropriately. The provider could not demonstrate that governance and assurance systems were in place to ensure the recording of consent or the review of DNACPR to assure that they were still valid.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. We were told clinicians understood the requirements of legislation and guidance when considering consent and decision-making. All but 2 members of staff had completed Mental Capacity Act training. The National GP Patient Survey found 86% of patients felt they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. The national average was 91%.