Carlisle Central 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

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. This is the first assessment for this newly registered service. This key question has been rated Good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

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

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had systems to identify people with undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber via the primary care network.

The provider 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. A remote review of the patient record system showed that patients generally received appropriate long-term condition reviews. We did some examples where patients had not had required blood tests within recommended timeframes, however we also saw that where tests were needed, the practice took reasonable steps to try and encourage patients to attend the practice for these. Where we identified patients who were overdue for follow up, these were actioned by the practice immediately. Patients with long-term conditions were offered an effective annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GPs worked with other health and care professionals to deliver a coordinated package of care.

The provider mostly 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. We did see an example of a time where a patient almost missed a placement with a service due to a delay in information being shared by the practice with other services, however the provider gave us evidence of the processes they have in place to improve communication with partners, such as a dedicated phone line which bypasses the need to contact reception.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff 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 provider routinely monitored people’s care and treatment to continuously improve it. However, they did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. The practice was below national targets for cervical screening and for childhood immunisations. The practice was aware of this and had introduced a recall system to ensure patients were contacted to attend screening appointments. We also saw that some patients with long-term conditions were overdue essential blood tests. Any patients we flagged with the practice were contacted immediately.

The provider 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.