Causeway Green 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

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.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community. 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 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 effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

Systems were in place to identify individuals with caring responsibilities, who were offered an annual review. Information provided by the practice showed there were a total of 64 people with caring responsibilities registered at the practice. All patients with a learning disability were invited to attend an annual health assessment. We found there were 13 patients on the learning disability register. We reviewed a random sample of 4 patient records and found the appropriate reviews and assessments had been completed.

The service always 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. They worked to develop evidence-based good practice and standards.

During the remote clinical review, we carried out a search to identify people with asthma who had been prescribed 2 or more courses of rescue steroids in the past 12 months. The search identified 40 people. We reviewed a random sample of 5 clinical records and found all patients had been treated appropriately, including management of symptoms and exacerbations in line with clinical guidance. Where ongoing review was required, patients were appropriately invited for asthma reviews, with evidence of follow-up and documentation in the clinical record. We found the practices’ systems supported proactive asthma care.

Further reviews of the clinical system identified people with diabetes who had a HbA1c of 75 and over. The search identified 37 patients. We reviewed a random sample of 5 clinical records and found the appropriate reviews had been completed and ongoing monitoring was in place with follow-up arrangements clearly documented.

An audit had been completed to assess whether patients with a history of prostate cancer who had been discharged from secondary care had received annual monitoring in primary care. The audit identified 5 patients who had been discharged from Urology to primary care for annual follow up. A review of each patient showed that 4 patients had received the appropriate checks in the past 12 months and 1 patient had tests booked. This demonstrated that the practice had achieved 100% in ensuring patients had been reviewed or had a review planned within a 12 month period.

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.

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, physiotherapists and social prescribers. People were able to receive co-ordinated care between the practice and the PCN.

The service always supported people to manage their health and wellbeing to fully 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 made reasonable adjustments to provide support to vulnerable patients. This included home visits for patients who were unable to attend the practice.

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.

Unverified data provided by the practice showed they had achieved the national targets for childhood immunisations and were slightly below the national target of 80% uptake for cervical screening for people aged between 25 to 49 years of age and for people aged 50 to 64 years. To encourage people to attend their appointments, appointments were available at different times throughout the week to provide choice and a range of availability.

From the clinical notes we reviewed, we found that 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. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.