Mitcham Family Practice

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• 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, and that staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating remains as Requires Improvement.

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 make sure people’s care and treatment was effective because they did not consistently make and document a complete assessment of their needs, in line with legislation and current evidence-based good practice and standards.

We looked at the records of 3 patients experiencing an exacerbation of one long-term condition. 2 of 3 the records reviewed records did not have enough detail to show that staff made a sufficient assessment of the patient before prescribing, and there was no rationale for this divergence from national guidelines in the notes of these patients at the time.

We saw that two patients with one condition did not have an active code for that condition on their patient record. The provider told us that this was intentional coding in response to patients not responding to follow up with the practice for a long period. This may present a potential risk to patients, particularly if care is transferred between providers or information is viewed through shared care records, as it may reduce visibility of an active long-term condition. It may also affect recall processes and limit opportunities for providers to encourage patients to re-engage with monitoring and review.

Feedback from people using the service was generally positive. 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 could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The service did not always deliver people’s care and treatment with them in line with legislation and current evidence-based good practice and standards.

We looked at the records of patients experiencing an exacerbation of one long-term condition. Patients were not followed up in line with national guidance to assess the effectiveness of treatment. Where clinical management differed from national guidance, we did not see a documented rationale for this in the patient records Patients received an annual review of their condition. However, we saw a record where it was not possible to evidence that the review was effective, as it did not accurately record the exacerbations the person had experienced. The provider told us that this was a documentation error.

There was no consistent system to follow up on people who did not respond to routine requests to have monitoring or review, or who were not requesting required medicines.

The service made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

The practice had moved to a different system to store patient records. There were some issues with using the codes on this system to allow patients to be identified and to record when medication reviews were completed.

The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

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 and tackling obesity.

The practice had not established effective systems to monitor people’s care and treatment to continuously improve it.

The practice had not met national targets for immunisations or cervical screening.The latest published immunisation data covers the period 01/04/2023 to 31/03/2024. The provider told us that shortly before this the service had changed to a new patient record system, and coding inconsistencies affected the data used for the national analysis. The practice sent us more recent data that showed that immunisations uptake had improved but remained below national targets. The practice data cannot be directly compared to the data used for reporting by CQC as it has not been nationally validated. The practice had analysed performance and had an action plan for improvement in place.

The practice told us that there was a period where staff changes meant cervical screening could only be carried out using appointments at weekends and at the local hub service. The practice had an action plan in place to improve uptake and showed us unverified data that suggested improvement, although this data cannot be compared directly to the data used by CQC for reporting. The practice now had two staff members who could carry out cervical smears and plans to increase capacity further, and to continue to improve take up.

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.