Rosedean 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

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. People with long term conditions did not always receive the appropriate health monitoring for their condition. 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.

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

Reception staff used digital flags within the care records system to highlight any specific individual needs and were aware of the processes to call for help in the event of a person’s deterioration. A staff member gave examples of when this was used, such as when a person fainted during an appointment.

Staff told us they recognised that people may need additional support to access the service through the digital triage system. Staff told us how they completed triage forms on behalf or with the person. One member of staff said; “We spend a lot of time filling in triage forms for people that aren’t able to do it themselves.”

The service was in the process of recruiting care coordinators (a non-clinical or clinically informed role to support people to navigate health and care services)

As part of our assessment clinical record searches were undertaken by a CQC GP Specialist Advisor. We found there were 24 people identified by the search as having a potential missed diagnosis of diabetes, a sample of 5 records reviewed demonstrated that people had received appropriate follow up.

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

As part of our assessment, a number of set clinical record searches were undertaken by a CQC GP Specialist Advisor.

Our clinical searches identified people with diabetes whose latest HbA1c was above 75mmol/mol. Our review showed these individuals had received the appropriate monitoring in line with national guidance.

Our clinical searches identified 743 people were diagnosed with asthma and 45 of these people had 2 or more courses of rescue steroids prescribed in the last 12 months. We reviewed 5 of these records and found 3 of these people were not properly assessed or followed up in line with guidance.

Our clinical searches identified 38 people who were diagnosed with Chronic Kidney Disease Stages 4 or 5 and found 6 people had not had the required monitoring in the last 9 months as per national guidelines. We reviewed 5 of these records and found 3 of these people were not properly assessed or followed up in line with guidance.

Our clinical searches identified 15 patients with hypothyroidism who had not had thyroid function test monitoring for 18 months. We reviewed 5 of these records and found that 2 of these people had not received the appropriate monitoring.

In response to this, the service took action by contacting all people affected and ensuring they had received reviews. To prevent this from happening again, the service introduced a new system for a central pharmacy team to complete a monthly audit to ensure people have been followed up and reviewed in line with guidance.

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 practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.
The service held a daily huddle each morning and during this time the team communicated any on the day changes or concerns relating to daily operations.
The service was part of a wider meeting within its Primary Care Network (PCN) where other external teams were involved such as the community nursing team. This provided an opportunity for the service to work as part of a multi-disciplinary team (MDT). An example of how this works in practice is where the MDT worked together to support a person’s discharge from hospital. The service also attended children’s health meetings as well as monthly frailty meetings with a geriatrician and people’s mental health. The services’ care management systems were accessible by the local geriatrician to be able to share information seamlessly.
The service worked with other teams and services to provide better outcomes for people using the service. For example, the service sought advice from the local respiratory team. A clinician working in the service told us they had a good working relationship with community based organisations such as the local opticians.
 

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 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.

The website promoted this and provided information about how people can be referred to Healthy Cornwall (a local public health partnership). Within the service, there was displayed information on notice boards to promote healthy living.

The service had a social prescribing link worker (a non-clinical practitioner who supported people to improve their health and wellbeing by connecting them with community-based services, activities and voluntary sector support) available within the service and staff at the practice could refer people to this service.

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.
The practice showed data to demonstrate their progress with national screening and immunisation targets. For childhood immunisations, the service was below the national targets for 2 of 3 required childhood immunisations.
The service recognised they needed to improve their uptake of childhood immunisation and had implemented processes to improve this. For example, monitoring children not brought to their appointment rates and contacting people to follow up on the nonattendance. The practice offered appointments throughout the day so families could attend. Promotion of immunisations was made through the service’s social media and on notice boards within the practice.
In addition, to increase cervical screening uptake the service offered opportunistic screening where available and was in the process of providing additional training to a practice nurse in order to be able to offer more appointments.
Clinical searches were undertaken to identify people who may be at risk of diabetes. Records showed that these people were appropriately reviewed by clinicians.
Our clinical searches also identified that where people were prescribed medicines that required breaks in treatment, such as Bisphosphonates (a medicine to strengthen bones) our clinical searches found that people had breaks in their treatment and appropriate follow up.
 

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.
The service had policies such as consent and mental capacity act to underpin the fundamentals of consent. Staff understood and applied legislation relating to consent and understood Gillick competence when working with children. However, we found that 6 staff did not have up to date training in Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) .