Two Rivers Medical Centre

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. This key question continued to be rated as good. Staff regularly reviewed people’s care and worked with other services to achieve this. Staff supported people to live healthier lives and where possible, reduce their future need for care and support. Some systems for long term condition monitoring needed strengthening to ensure people were monitored effectively.

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 their health, care, wellbeing and communication needs with them.

The majority of feedback from people about the clinical care provided was positive. People were involved in any assessment of their needs, which included their carers, as appropriate. Some care home staff received weekly calls and visits for people to be assessed, which they reported worked well. New care home residents were able to register quickly and easily. A named GP was responsible for each care home and most care homes had a named clinician who visited regularly. Care home staff had a direct phone number to the Care Coordinator to advise of people who needed to be assessed.

Staff used digital flags within care records to highlight any individual communication or accessibility needs. This information was gathered at the point of registration and opportunistically. Staff shared examples such as the requirement for longer appointments or for an interpreter. The practice had a mobile phone used by people who were deaf or had difficulty hearing to text appointment or administration requests.

The practice had systems to identify and prioritise care and treatment for people who were vulnerable. All people with a severe mental illness and all people with a learning disability were offered an annual health assessment. Practice Nurses and Nurse Associates were trained to complete these and reasonable adjustments were in place to support people’s attendance. 99% of people with a learning disability had been offered a health check, and 90% of people had a completed health check in the last year.

Systems were in place to identify people with caring responsibilities at registration, opportunistically, and through self-reporting. They held a carers’ register and 3.6% of the practice population were registered as carers. A Care Coordinator supported as needed, for example by signposting to Suffolk Family Carers and referring to ‘respite on prescription’ who may provide funding to help pay for replacement care whilst a carer was away for a planned medical procedure, appointment or treatment.

We observed from the clinical searches the service delivered evidence-based care although arrangements for people who repeatedly failed to respond to invites and some monitoring processes required review. For example, the follow up of people with asthma who were prescribed emergency steroids. The practice took immediate action and activated a pop-up alert which advised the prescriber the person needed follow up, with a preset message and brief questionnaire which was sent to the person. Responses were reviewed by asthma nurses and any issues were reviewed by the duty GP.

One search identified 1114 people with hypothyroidism of which 70 people potentially had not had blood monitoring in the past 18 months. We reviewed the records of 5 people and found although 4 people were overdue monitoring, 3 of these people had been invited and not attended. At the site visit we found the person overdue blood monitoring had been invited for this. The 3 people had been sent communication which advised due to safety issues their medicine had been reduced to a 7-day supply until blood monitoring was performed. Arrangements were in place to follow up with their GP if there remained no response. The practice had started to review the records of the remaining people and confirmed 20 had received blood monitoring and they had invited the other people to have blood monitoring. An audit had been set up to ensure the required monitoring was completed.

Another search identified out of 1707 people with diabetes, 190 people had a blood result which was above the recommended level. We reviewed a sample of 5 people. We found 1 person was overdue diabetes monitoring and although they had been invited, they had not attended. At the site visit we found this person had been sent communication to advise their medication had been reduced to a 7-day supply until they were up to date with diabetes monitoring. Arrangements were in place to follow up with their GP if there remained no response. The practice had started to review the records of the remaining people to identify who needed diabetes monitoring and advised this would be arranged.

A further search identified 132 people with chronic kidney disease at stage 4 or 5, of which 22 people potentially had not received appropriate monitoring. We reviewed the records of 5 people and found they had received appropriate monitoring. The practice had started to review the records of the remaining people to identify if appropriate monitoring had been received and advised this would be arranged if needed.

However, the majority of people were satisfied with the care and treatment they received. Representatives from care homes gave positive feedback regarding the clinical knowledge and skills of staff.

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. People were recalled according to their month of birth. People with multiple long-term conditions were reviewed during one longer appointment where possible. Arrangements were in place to coordinate any tests required, so results were available at the time of the review appointment.

Staff told us that the leaders provided opportunities for them to keep up to date with current guidelines, and changes to evidence-based care and treatment. They gave examples of clinical protocols and tools which they had shared with the GP Partners who had agreed to use them in the practice. One example was a health management tool for healthcare providers who cared for people with diabetes. Staff attended meetings to discuss cases and new guidelines, and minutes of the meetings were available should they need them. The practice monitored and improved outcomes for people by carrying out clinical audits.

The service worked well across teams and services to support people. They shared assessments of people’s needs when they moved between different services.

People who provided feedback for this assessment had no specific views or concerns in this area.Care home representatives were generally positive about how services worked together.

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.

Arrangements were in place for practice teams to support each other. For example, all staff who were trained supported at times of peak telephone demand and the nursing team supported colleagues who were running behind with their appointments.

Stakeholder feedback was positive, and an example given of support to another practice to improve care home arrangements.

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.

People who provided feedback for this assessment had no specific views or concerns in this area. Representatives from care homes told us people received general and specific health checks and clinical staff visited to administer vaccinations.

A range of services were available to support people to improve their health and wellbeing. This included for example, first contact physiotherapists, social prescribers, and Care Coordinators, who were available on different days and times at the practice. NHS health checks were offered to people aged 40 to 74 years. Healthy living information was available in the waiting room, around the practice and on the practice website.

Staff supported national priorities and initiatives to improve population health, which included stopping smoking and tackling obesity. Staff gave examples of where people had been positively supported to live healthier lives, which included healthy eating, weight management and wellbeing walks. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

People who provided feedback for this assessment had no specific views or concerns in this area.

Practice staff had worked to improve the uptake of childhood immunisation and had achieved the World Health Organisation target for one of the childhood immunisation indicators. Practice leaders were aware that their performance for cervical cancer screening was lower than the national target and had taken action to improve this and continued to monitor and review uptake.

The practice offered a flexible approach to cervical screening appointments for people who worked which included early morning, late evening and Saturday morning appointments. People could book an appointment online, by telephone or in person, to discuss any concerns they had about cervical screening. Discussions were held opportunistically, and prompts for discussion were given for example, during family planning and post-natal appointments. Arrangements were in place to follow up people when they did not respond to an invitation or attend their appointment. The practice had recently changed and improved this system to ensure consistency in approach and to further understand barriers and offer support. Information was available in the practice and on the practice website to encourage uptake. The practice planned to promote the upcoming cervical screening awareness week. Examples of reasonable adjustments to encourage uptake for people with a disability, people from ethnic minority groups and people from the LGBTQ+ population were detailed in the practice policy.

The practice worked together with the Severe Mental Impairment Suffolk Physical Health Team to identify where intervention could best be delivered to improve people’s health outcomes. The team had been able to hold physical health clinics at the practice, which provided an alternative approach to engage with people and promoted equality and inclusivity. A data sharing agreement was in place which allowed access to people’s records for direct recording of information.

Arrangements were in place to send information to people overdue breast and bowel cancer screening. Since October 2024, 838 people had been informed about how to obtain a bowel cancer screening kit, 349 completed the test with 3 people followed up for abnormal results.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. People’s feedback demonstrated they felt at ease during consultations, were listened to and procedures were explained well. People were appropriately informed when making care and treatment decisions. Feedback from people who had undergone minor surgery was obtained and feedback we saw which related to consent showed high satisfaction.

Clinicians told us they supported people to make decisions, and where appropriate, they assessed and recorded a person’s mental capacity to make a decision. Clinicians told us they always obtained consent from people and offered a chaperone where appropriate, which was recorded on the clinical system. They told us for some procedures written consent was discussed with and obtained from people before a procedure was undertaken and we saw evidence of this in people’s clinical records. Staff told us they had completed training on consent and the Mental Capacity Act. Staff we spoke with had a good understanding of consent.

People were offered a chaperone, and posters were displayed in the practice informing people this was available to them. Staff who carried out chaperone duties were trained for the role and had received a disclosure and barring (DBS) check. The practice had systems and processes in place to obtain consent to care and treatment in line with legislation and guidance.