Shirley Health Partnership

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.

This is the first inspection for this service following its relocation to new premises This key question has been rated as 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.

Feedback from people using the service was positive. People reported feeling involved in the assessment of their needs and felt confident that staff understood their individual and cultural needs.

Staff were aware of the needs of the local community and used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments, easy-read documents 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.

The service had effective systems to identify people with previously undiagnosed conditions. For example, our remote clinical searches identified 21 people who may have a potential missed diagnosis of diabetes. We reviewed 5 of these in more detail and 4 people had received a diabetes diagnosis with appropriate coding and monitoring processes and 1 who had a personalised, agreed care plan in place. The service confirmed it would review all records to ensure the correct coding had been applied to people’s notes.

The service planned and delivered people’s care and treatment with them, including what was important to them. They did this in line with 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. Clinical records we saw demonstrated care was provided in line with current guidance.

Information on best practice was shared with staff at clinical meetings. The service had also implemented peer review sessions to promote sharing of learning.

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.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The service worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The service held monthly multidisciplinary team (MDT) meetings. Local community nursing teams provided positive feedback as part of this assessment. They told us they have access to a ‘bypass’ telephone line for urgent matters and get a timely response from the service when it is required.

Shared prescribing clinics were run with ‘Change Grow Live’ (CGL is a national charity that offers help with drugs, alcohol, housing, justice or health) to support people through substance misuse recovery. We spoke with CGL as part of this assessment and they reported sessions were effective, describing clinicians as professional, caring, and outcomes for people as positive.

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.

Staff focussed on identifying risks to people’s health, including those in the last 12 months of their lives, people 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.

The service held a ‘Dementia Awareness Support’ event for people and their families living with dementia and memory loss. They invited other services to attend including; Age UK and Southampton Living Well. People were provided with information packs and signposting to other support services. People who attended the sessions said, ‘it was a brilliant and busy day’ and ‘such a great event’.

During our onsite visit, in the reception area we observed several short information videos via television screens, including NHS app information, public health campaigns and local information for people to access as they waited for their appointment.

The service had 2 ‘health pods’ for people to use in private spaces within the reception area, to check their blood pressure and other health indicators such as weight. The system was available in 19 different languages. The health data gathered from the use of the pods also fed into people’s clinical record for review. The service had arranged an upcoming ‘know your numbers’ day for people to attend the service and complete health checks.

In addition, the service worked collaboratively with the local primary care network (PCN) to enhance care provision by offering smoking cessation, health and wellbeing coaching and support from social prescribers.

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.

Pathology results were reviewed and actioned in a timely manner and people were supported to understand and manage their individual needs.

The service met 4 out of 5 of their national childhood immunisation targets and worked to improve the remaining target for age 5 children who have received two doses of the MMR immunisation. The service also focused on improving their uptake of cervical screening by organising cervical screening focus weeks, increasing appointment availability and offering flexibility across all opening hours.

The service carried out some audits including asthma, Mounjaro (weight loss injection) with contraception prescribing and high-dose opioid use. As a result of the opioid audit, the service demonstrated there had been a significant reduction in high-dose opioid prescribing, for example, out of 40 people originally receiving high-dose opioids, this had been reduced to 6, with personalised support given to people throughout the process. This included consistent GP oversight and letters being sent with key information explaining ‘Why does my GP want to reduce my pain killers?’.

The service shared and discussed the results and learning from the audits with staff to improve care for people.

From the clinical notes we reviewed during clinical searches, we noted people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

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 in clinical records, and support was available where there were concerns around people’s capacity.

Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. During our onsite visit, we reviewed 5 DNACPR records and noted DNACPR forms were being appropriately completed and reviewed. Relevant documentation was also present in the care records for those who lacked the capacity to make decisions. For people who lacked capacity, the necessary documentation relating to both the capacity assessment and the decision-making process was present in their care records.