Umbrella Medical at Hatherton 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

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent.

This service scored 67 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from people using the practice was positive. People felt involved in any assessment of their needs and felt confident that 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. 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. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The provider identified 58 patients on the learning disability register, 49 annual health checks have been completed, achieving an 86% completion rate. Patients who did not complete their health check either declined or did not attend despite multiple invitations. The practice worked with neighbourhood teams, the Mental Health Trust, and paramedic services to support engagement, including home visits where appropriate.

The practice used the Electronic Frailty Index (eFI) a risk stratification and prioritisation tool embedded within their clinical system to identify patients with moderate or severe frailty. They used this index tool as well as their local and clinical knowledge. Structured annual medication reviews took place. The practice worked to ensure proactive care for patients identified with moderate to severe frailty.

The practice met the accessible information standard. For example, a hearing loop was present, interpretation services were available and letters in braille could be requested. Staff could refer patients with social needs, such as those experiencing social isolation or housing difficulties to a social prescriber within the primary care network.

Staff checked people’s health, care, and wellbeing needs during health reviews. 85% of patients that completed the National GP Patient Survey agreed that they felt their needs were met during their last GP appointment which was slightly lower than the local average of 88% and the national average of 90%. 89% of respondents felt the healthcare professional they saw had all the information they needed about them during their last GP appointment which was slightly lower than the local average of 91% and national average of 92%. To address these scores, the practice had collaborated with the Integrated Care Board (ICB) to develop an action plan aimed at strengthening patient engagement, enhancing patient experience and improving service quality.

The practice mostly planned and delivered people’s care and treatment with them, including what was important and mattered to them.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical meetings were held to discuss specific patients that related to clinical updates. Multi-disciplinary team meetings were held to ensure staff were updated with the latest information guidance and changes within the practice. Urgent messages were displayed through a task on the computer screen. Remote clinical searches of patient clinical records reviewed the monitoring of people with long-term conditions to assess if National Institute for Health and Care Excellence (NICE) recommendations were followed.

Clinical records we saw demonstrated care was not always provided in line with current guidance. We identified some issues around a lack of a consistent follow up approach for patients with an exacerbation of asthma and prescribed steroids. The provider reviewed the records and put in place monitoring to ensure consistent follow-ups. Our clinical searches identified several patients who may have had a missed diagnosis of diabetes. On reviewing 5 patient records, none had been correctly coded as having type 2 diabetes. 2 patients with diabetes had no blood test follow-up and medication review. These findings were actioned by the provider following our feedback. Our clinical searches found there were 911 patients with hypothyroidism, 10 patients were potentially overdue thyroid monitoring, meaning they could be at risk of being under or over treated for their condition. We sampled 5 patient records, all 5 patients were overdue monitoring. We saw that patients had been contacted and had not attended.

The practice 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.

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.

The practice regularly held multidisciplinary team meetings. For example, safeguarding meetings were held with the care coordinator, GP partners, paramedics and care home coordinator. School nurses also attended meetings with safeguarding leads. Staff were supportive of each other to ensure they had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other practices within the primary care network (PCN) to share knowledge to improve patient care. Patients had access to services provided by the PCN, including social prescribers. To ensure staff were able to work together effectively, the practice adopted an open-door policy to encourage staff to speak up so that any queries were resolved to ensure a positive working environment. Each staff member knew their roles and responsibilities.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. The practice 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, patients 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.

Patients were encouraged to take an active role in reviewing their own health and wellbeing so they would recognise changes. For example, information and resources were available throughout the practice to support patients in managing their health and making informed decisions. Many staff members were able to advise and signpost patients to the appropriate services to improve or maintain their care such as to the social prescriber or care co-ordinators. Health promotion material was observed in the practice, and further information could be found on their website that supported national priorities and initiatives to improve population health by supporting people. Senior pharmacists had oversight of quality improvement in prescribing areas. Educational videos were displayed in reception areas on TV screens, to promote health awareness and support patients to make informed lifestyle choices to improve health outcomes.

NHS Health Checks were offered to eligible patients aged 40–74 without pre-existing CVD (Cardiovascular disease). The practice shared data which showed positive improvements with this service achieving an increase of 234%. New patients who registered were invited to book a health check with the practice.

Awareness Days took place including health promotion, palliative care day and carers events.

The practice routinely monitored people’s care and treatment to continuously improve their health outcomes. However, at the time of our assessment, the latest published information from the UK Health Security Agency (UKHSA) showed that the practice was below the World Health Organisation target of 95% for the number of children immunised against various infectious childhood diseases such as children aged 5 who should have received immunisations for measles, mumps and rubella. The latest published information (2024-2025) from NHS Digital showed the practice’s uptake of cervical cancer screening for women aged 25 to 49 years old was below the 80% national target and was observed as 68%. The practice’s uptake of cervical cancer screening for women aged 50 to 64 years old was below the 80% national target and was observed as 77%. Staff told us that over the last 12 months they had increased the appointments and the uptake in cervical screening. Patients were contacted by the nursing team via phone or online messaging to encourage screening uptake and re-book appointments.

The practice 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.

The provider maintained a consent guidance document, and all clinical staff had completed Mental Capacity Act (MCA) training, with non-clinical staff training proposed.

Staff had completed learning disability and autism training to at least Tier 1 and for those yet to complete Tier 2 training this was planned.

The practice told patients about their rights around consent and respected these when delivering care and treatment. We spoke with clinical and non-clinical staff, and they all had a detailed understanding of consent. Staff understood the importance of ensuring that people fully understood what they were consenting to and respected the importance of obtaining consent before they delivered care or treatment. Patient’s capacity and ability to consent were considered and clearly recorded. Patients received information about their care and treatment in a way they could understand. Chaperones were available upon request.