Portway Family Practice

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.

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

This service scored 71 (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. 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. A portable hearing loop was available at reception. 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 provider had systems in place to identify people with previously undiagnosed conditions. Care plans and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) records were completed and reviewed regularly. Systems were in place to identify individuals with caring responsibilities. All patients with a learning disability were invited to attend an annual health assessment and long-term condition reviews were carried out to those patients who were housebound.

There were appropriate referral pathways to make sure that patients’ needs were addressed. For example, staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. We found that staff had the appropriate skills and training to carry out reviews where appropriate.

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

Our remote clinical searches identified 1 out of 261 patients with hypothyroidism (a condition where the thyroid does not produce enough hormones) who had not received the appropriate monitoring in the last 18 months. We reviewed the record and found appropriate action had been taken.

Our remote clinical search identified 16 patients with asthma who had been prescribed 2 or more courses of rescue steroids in the last 12 months. Of the 5 patients reviewed, we found 4 had an annual asthma review and 1 patient was overdue; however, all 5 patients had not had a follow up review following an exacerbation within a specified timeframe. We discussed this with the practice who took action to review their processes to ensure this was actioned appropriately.

Our remote clinical search identified the practice had 92 out of 587 patients with diabetes who’s latest HbA1c (blood glucose) level was consistently high. We reviewed 5 patients and found all patients had been reviewed; however, they had not been coded. The practice took action to address this as part of our assessment.

Generally, we found the remote clinical searches we undertook which included reviewing the monitoring of patients with long-term conditions to assess if National Institute for Health and Care Excellence (NICE) recommendations were being followed and the

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 told us that they had access to the information they need to appropriately assess, plan and deliver people’s care, treatment and support and they had enough information to plan and refer people and receive subsequent results and information following referral. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

There were systems and processes in place to enable information to be shared between the provider and services to ensure continuity of care. Regular meetings were held with multi-disciplinary teams to ensure care was co-ordinated effectively.

The Primary Care Network (PCN) helped to support the practice by providing links to pharmacists, First Contact Physiotherapists, Care Coordinator, Digital Care Coordinator, Pharmacy Technician, and Social Prescriber. People were able to receive co-ordinated care between the practice and the PCN.

The practice provided care to 2 residential care homes and maintained effective working relationships to support residents’ healthcare needs. We spoke with representatives from one of the care homes, who spoke positively about the service and described the support provided by the practice as responsive and well-coordinated. Feedback highlighted good communication, timely access to clinical advice, and ongoing collaboration with the care home to ensure residents received appropriate and person-centred care.

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.

There were flags on patients’ records who were vulnerable and required ongoing monitoring and recalls in place to review patients and educate them to manage their health needs. There was regular engagement with community services and referral pathways in place. The practice website detailed information and links for health promotion, health conditions and common health questions.

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. For example, over the past 12 months, the practice had hosted a range of health promotion activities, including a Women’s Health Event, a heart failure awareness event, and initiatives to support Mental Health Awareness Week.

Staff actively signposted patients to local support services offering information, education, and tailored advice based on individual needs. Patients were encouraged to participate in national health initiatives, such as cancer screening programmes and childhood immunisations.

The latest GP Patient Survey carried out, showed that 83% of respondents felt their needs had been met during their last general practice appointment which was slightly below the local average of 88% and the national average of 90%.

The service routinely monitored people's care and treatment. However, outcomes were not always in line with national targets across all areas.

The practice was performing in line with national averages for both bowel and breast cancer screening. Cervical screening uptake was above the locally agreed target of 66%; however, it remained below the national target of 80%. The practice achieved a screening uptake rate of 72% for women aged 25 to 49 years and 74% for women aged 50 to 64 years. Childhood immunisation uptake ranged between 90% and 94% across the measured indicators.

Leaders demonstrated awareness of the factors impacting uptake, including high levels of deprivation within the practice population which affected patients’ ability to engage with screening programmes. To encourage people to attend their appointments, these were made available at different times throughout the week to provide choice and a range of availability. The practice had implemented targeted actions to mitigate these challenges such as hosting cancer awareness events and women’s health education events aimed to increase uptake and educated the practice population. At the time of our assessment, the practice was in the process of delivering a health promotion campaign through a radio station. This initiative aimed to raise awareness of health services and key health messages among Punjabi-speaking patients, demonstrating the practice’s commitment to engaging with diverse communities and ensuring information was accessible to different population groups.

The practice had an established programme of clinical and non-clinical audits and action plans aimed at driving continuous improvement in patient care and operational efficiency. For example, the practice had implemented an audit to find missing cases of diabetes in primary care, an audit had been carried out for the coding of chronic kidney disease and reviewing lipid management in secondary prevention of cardiovascular disease.

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. There were policies and procedures in place such as mental capacity and best interest meeting. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.