Station 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. 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. Staff involved those important to people took decisions in people’s best interests where they did not have capacity. However, we found care was not always based on latest evidence and good practice.

This service scored 62 (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 make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care and wellbeing needs with them.
GPs, nurses and pharmacists conducted medication reviews using templates in the patients’ record to support the review of people’s wider health and wellbeing. We found there had been 1466 reviews completed in the last three months.

However, we found the service did not always have effective systems to identify people with previously undiagnosed conditions when bloods tests suggested they might. This included identifying patients from blood test results and coding them to ensure ongoing care and support was provided.

For example, we found 457 patients had received a blood test which indicated they might have chronic kidney disease (CKD). A proportion of these patients had not been coded in the record or followed up to ensure appropriate care was delivered.

Digital flags within the care records system were used to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. 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. However, they did not always follow 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 by disseminating updates to all relevant staff members.
However, our searches revealed that not all care adhered to best practice guidelines set by the National Institute for Health and Care Excellence (NICE). For example, some patients prescribed steroids for asthma were not followed up within a week to assess their response to treatment.

Additionally, out of 1841 patients with an under active thyroid, 120 patients taking thyroid medication were not receiving regular blood tests to ensure appropriate dosing.
Of the 2,894 patients with diabetes, 463 had not received up-to-date health monitoring, potentially impacting the effectiveness of their treatment. While we found a proportion of these patients had been invited for reviews, they had not engaged with the service and not been followed up.

The management team put in an action plan following the inspection to improve the recalling and monitoring of patients.
 

The practice worked well across teams and services to support patients. Staff had access to the information they needed to appropriately assess, plan, and deliver care, treatment, and support.
We saw there were systems and processes in place to ensure care was delivered and reviewed in a coordinated way which included local care homes, people receiving end-of-life care and those with a learning disability. There were regular documented multi-disciplinary team meetings. Information was shared with and received from out-of-hours services through their clinical system and there were systems in place to follow-up on information received.
 

The practice supported patients to manage their health and wellbeing to maximise their independence, choice and control. Staff told us they were committed to promoting and encouraging patients to live heathier lives. They told us they used consultations to opportunistically discuss health choices and provide supporting information. This included encouraging patients to attend health checks and reviews and signposting to support groups and self-help advice.

Patients with a respiratory condition who had experienced a worsening episode were given a pack with advice and supportive equipment to help them manage their condition.

Staff told us they supported national health priorities, initiatives and screening programmes to improve the population’s health, for example, breast and bowel cancer screening. Patients had access to a social prescriber, who helped them improve their health, wellbeing and social welfare by connecting them to community services. We saw the practice website had links to health and wellbeing information.

The practice had some QR codes around the reception area with links to health promotion and events. Leaflets were available on request from reception and could be sent out digitally by clinicians when additional information was beneficial. Where appropriate, the practice signposted patients to the NHS Community Pharmacist Consultation Service.

The practice routinely monitored patient care and treatment to continuously improve it. We saw that the practice had a programme of quality improvement, including clinical and non-clinical audits, to drive improvements in care and treatment.

The service maintained patient registers, including those for individuals with long-term conditions and learning disabilities. Our searches confirmed the presence of a recall system designed to ensure patients were offered appropriate health assessments and checks.

However, when patients did not engage or attend appointments, they were often allowed to continue medications that might not be the correct dose or type. Since the inspection, the service has provided evidence of an improved recall system and enhanced follow-up processes to address this issue.
 

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.