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Inspection Summary


Overall summary & rating

Good

Updated 13 February 2019

This practice is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Crossways Surgery on 14 December 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had systems to manage risk and to ensure that safety incidents were less likely to happen. When safety incidents did happen, the practice learned from them and improved their processes.
  • There were systems in place to reduce risks to patient safety. A risk register was in place and this was monitored and fed in to the provider’s risk register.
  • Procedures to prevent the spread of infection were in place and regular Infection control and cleanliness audits were carried out.
  • Systems were in place to deal with medical emergencies and staff were trained in basic life support.
  • Clinicians assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Systems to review the effectiveness and appropriateness of the care provided were in place and being developed further.
  • Clinical audits were carried out and the results of these were used to improve outcomes for patients.
  • Data showed that outcomes for patients at this practice were similar to outcomes for patients locally and nationally.
  • Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Staff told us they felt supported in their roles and with their professional development.
  • Patients told us they were treated with dignity and respect and they were involved in decisions about their care and treatment.
  • The provider learnt from complaints and made improvements to the service as a result.
  • There was a clear leadership and staff structure and staff understood their roles and responsibilities.
  • The provider had a clear vision to provide a safe, good quality service.
  • Systems were in place to check on the quality of the service.
  • There were systems in place for clinical governance and these were being further developed.

The areas where the provider should make improvements are:

  • Review the newly introduced governance systems for example, provider level oversight of; performance data, medicines management and health safety related checks to ensure these are effective in monitoring the quality of the service provided and drive improvement.
  • Ensure a system is in place for monitoring patients referred for tests or investigations under the two-week wait rule.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 13 February 2019

We rated the practice as good for providing safe services.

Safety systems and processes

The practice had systems to keep people safe and safeguarded from abuse.

  • All staff received up-to-date safeguarding training appropriate to their role. Alerts were recorded on the electronic patient records system to identify if a child or adult was at risk. There was a lead member of staff for safeguarding. Staff we spoke with knew how to identify and report concerns and they told us they took steps to protect patients from abuse, including working with other agencies.
  • Staff who acted as chaperones were trained for their role and had undergone a Disclosure and Barring Service (DBS) check. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.)
  • Staff recruitment processes included ensuring appropriate pre-employment checks had been carried out prior to staff appointments.
  • Procedures were in place to ensure appropriate standards of hygiene were maintained and to prevent the spread of infection. Monthly cleanliness and infection control audits were carried out and the results of these were submitted to the provider for organisational oversight.
  • Arrangements were in place to ensure that facilities and equipment were safe and in good working order.
  • Arrangements were in place for managing waste and clinical specimens.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness and busy periods.
  • There was an induction system for staff tailored to their role.
  • The practice was equipped to deal with medical emergencies and staff were trained in emergency procedures.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention.
  • Clinical staff had been provided with information on how to identify and manage patients with severe infections including sepsis. Administrative staff had been provided with guidance on sepsis risk.
  • Health and safety procedures were in place.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were managed in a way that kept patients safe.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. Referrals to other services were made promptly and in line with protocols and information received from secondary care or other agencies was dealt with in a timely manner including the management of test results.

Appropriate and safe use of medicines

The practice had systems for the appropriate and safe handling of medicines.

  • Annual medicine reviews were carried out for patients.
  • We looked at how repeat prescribing was managed for patients who were taking potentially harmful medicines. GPs were responsible for ensuring all appropriate checks had been carried out before issuing a repeat prescription and for the sample of patients we looked at this had been managed appropriately. Data facilitators attended the practice on a weekly basis and they shared information about these checks with the practice manager. There was no monitoring or oversight of repeat prescribing of these medicines by the provider to ensure a consistent and fail-safe approach. However, the provider was looking at how they could use this data in their oversight of this area of practice.
  • Regular medicines audits were carried out with the support of the local Clinical Commissioning Group (CCG) pharmacy team.
  • Medicines prescribing data for the practice was comparable to national prescribing data. The practice made improvements to prescribing in line with best practice guidance and targets to reduce the prescribing of particular medicines.
  • Medicines for use in an emergency were readily available to staff and there was a system in place to check that medicines were in date and fit for use. An audit of emergency medicines had been carried out and the provider had oversight of the emergency medicines held at each practice.

Track record on safety

The practice had a good track record on safety.

  • The provider assessed, monitored and reviewed risks and took action to mitigate risks to the safety of patients and staff.
  • Risk assessments had been carried out in relation to health and safety related issues. For example, a fire risk assessment and prevention plan was in place and measures were taken to mitigate the risk of fire.
  • A range of health and safety policies were available to staff.
  • The practice had a business continuity plan in place for major incidents such as power failure or building damage.
  • Incidents were reported to the provider and these were shared at weekly meetings, fully investigated and action was taken in response to the findings. Lessons were then shared appropriately. All incidents had to be signed off by a senior manager of the organisation.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • There were systems for identifying and reporting significant events and incidents and for sharing any lessons learned from events so as to improve the safety of the service. We viewed examples of incidents that had been reported. The provider had carried out a detailed analysis of these and shared the learning from this.
  • Staff understood their duty to raise concerns and report incidents and near misses. Staff told us they felt supported to report concerns.
  • There was a system for receiving and acting on safety alerts and we saw examples of the actions taken by the provider in response to alerts.
  • The practice learned from external safety events as well as patient and medicine safety alerts.

Please refer to the Evidence Tables for further information.

Effective

Good

Updated 13 February 2019

Effective needs assessment, care and treatment

Clinicians assessed needs and delivered care and treatment in line with current guidance and were supported by clear clinical pathways and protocols.

  • Clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance.
  • Systems were in place to keep clinicians up to date with current evidence-based practice.
  • The provider produced a monthly paper to update the clinical team on any updates in guidance.
  • Clinical meetings were used to discuss best practice guidance and to look at the care and treatment provided to patients.
  • Performance data was monitored to improve outcomes for patients.
  • Data showed that outcomes for patients at this practice were comparable to those for patients locally and nationally.
  • Prescribing data showed that the practice was in line with local and national averages for prescribing medicines.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Information on how to respond to suspected sepsis was displayed in treatment rooms and in the reception area. Clinical staff we spoke with were clear on the guidance for recognising and responding to suspected sepsis.

Older people:

  • The practice kept up to date registers of patients with a range of health conditions (including conditions common in older people) and used this information to plan reviews of health care and to offer services such as vaccinations for flu.
  • Nationally reported data showed that outcomes for patients with conditions commonly found in older people at this practice were comparable to or better than outcomes for patients locally and nationally.
  • The practice maintained a register of frail elderly patients to review their needs and provide anticipatory care plans.
  • Book on the day appointments allowed for rapid access to meet the needs of older patients with co-morbidities.
  • The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any changes in their needs.
  • The GPs worked in conjunction with community services and secondary care to support patients who were nearing the end of their life.
  • The practice used the ‘Gold Standard Framework’ (this is a systematic evidence based approach to improving the support and palliative care of patients nearing the end of their life) to ensure patients received appropriate care.

People with long-term conditions:

  • The practice held information about the prevalence of specific long-term conditions within its patient population. This included conditions such as diabetes, chronic obstructive pulmonary disease (COPD), cardio vascular disease and hypertension. The information was used to target service provision, for example to ensure patients who required immunisations received these.
  • The practice used a system of coding and alerts within the clinical record system to ensure that patients with specific needs were highlighted to staff on opening their clinical record.
  • Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met.
  • GPs followed up patients who had received treatment in hospital or through the out of hours service.
  • Data from 2017 to 2018 showed that the practice was performing in comparison to or better than practices locally and nationally for the care and treatment of people with chronic health conditions.
  • Clinical staff who were responsible for reviewing the needs of patients with long term conditions had received training appropriate to their role.
  • Patients were provided with advice and guidance about prevention and management of their health conditions and were signposted to support services.

Families, children and young people:

  • Childhood immunisations were carried out in line with the national childhood vaccination programme. Uptake rates for the vaccines given met the World Health Organisation (WHO) target percentage of 90% in most areas.
  • The practice monitored non-attendance of babies and children at vaccination clinics and staff told us they would report any concerns they identified to relevant professionals.
  • There were systems in place to identify and follow up children living in disadvantaged circumstances and those who were at risk. A designated lead was in place for safeguarding. Staff had undergone regular safeguarding training and those we spoke with had appropriate knowledge about child protection and had ready access to safeguarding policies and procedures.

Working age people (including those recently retired and students):

  • The practice’s encouraged cancer screening uptake for patients in this age group. Uptake rates were comparable to local and national averages.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances in order to provide the services patients required. For example, a register of people who had a learning disability was maintained to ensure patients were provided with an annual health check and to ensure longer appointments were provided for patients who required this.
  • The practice worked with other health and social care professionals in the case management of vulnerable people.
  • Staff had been provided with training in the forms of abuse and how to recognise it in vulnerable adults
  • Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours. Staff provided examples of when they had recognised signs of potential abuse in vulnerable adults and how they had acted to report their concerns.
  • The practice provided appropriate access and facilities for people who were disabled.
  • Information and advice was available about how patients could access a range of support groups and voluntary organisations.

People experiencing poor mental health (including people with dementia):

  • The practice held a register of patients experiencing poor mental health and these patients were offered an annual review of their physical and mental health.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected a referral was made for assessment and diagnosis.
  • Data about how people with mental health needs were supported showed that outcomes for patients using this practice were comparable with or better than local and national averages. For example, the percentage of patients diagnosed with dementia whose care had been reviewed in a face-to-face review in the preceding 12 months was 89% (national average 83%). The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who had a comprehensive, agreed care plan in the preceding 12 months was 92% (national average of 90%).
  • A system was in place to prompt patients for medicines reviews at intervals suitable to the medicines they were prescribed.
  • Patients could be referred to a designated dementia support worker at one of the provider’s other locations.
  • The provider was developing work with a local secondary care provider looking at referral pathways for the patients with more complex needs.

Monitoring care and treatment

The practice had a programme of quality improvement activity and reviewed the effectiveness and appropriateness of the care provided.

  • Data from the QOF from April 2016 to March 2017 showed performance in outcomes for patients was comparable to those of the Clinical Commissioning Group (CCG) and national averages.
  • Clinical audits were carried out to improve outcomes for patients. Clinical audit is a way to find out if the care and treatment being provided is in line with best practice and it enables providers to know if the service is doing well and where they could make improvements. The aim is to promote improvements to the quality of outcomes for patients. We viewed a sample of audits that demonstrated that the provider has assessed and made improvements to the treatment provided to patients. These included: an audit into the prescribing of a specific medication and renal function and an audit into antibiotic prescribing for urinary tract infections.
  • The provider intended to introduce a new programme of quarterly clinical supervision meetings for GPs across their primary care practices.
  • A system was not in place for monitoring patients referred for tests or investigations under the two-week wait rule.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • Staff had been provided with training in core mandatory training topics and in topics relevant to their roles and responsibilities. For example, those whose role included immunisation and taking samples for the cervical screening programme had received specific training for these roles.
  • Staff told us they were encouraged and given opportunities to develop. They were provided with on-going support including; an induction process, annual appraisal and support for revalidation.
  • The provider had assessed the learning needs of staff and provided protected time to enable staff to undergo training and to meet their professional development. An up to date record of training was maintained and staff files contained up to date information about their training.
  • GPs were encouraged to attend regular education events organised by the provider and the Clinical Commissioning Group (CCG).
  • A shared clinical development group had been established to look at improving some of the processes in place across the practices.
  • Practice manager meetings and practice nurse meetings were held to support these groups of staff across the providers primary care locations.

Coordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

  • The information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way through the practice’s patient record system and intranet system.
  • The practice shared information with relevant professionals as part of their delivery of care and treatment for patients.
  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital.
  • The practice worked with patients to develop personal care plans that were shared with relevant agencies.
  • The practice ensured that end of life care was delivered in a coordinated way which considered the needs of different patients, including those who may be vulnerable because of their circumstances.

Helping patients to live healthier lives

Staff supported patients to live healthier lives.

  • The practice identified patients who may be in need of extra support and directed them to relevant services. This included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, by referring patients for smoking cessation or dietary advice.
  • Health promotion information and information and advice about how patients could access a range of support groups and voluntary organisations was available in the reception area.
  • Cancer screening uptake rates were comparable to local and national averages.

Consent to care and treatment

Staff sought patients’ consent to care and treatment in line with legislation and guidance.

  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinical staff were aware of their responsibility to carry out assessments of capacity to consent for children and young people in line with relevant guidance.

Please refer to the Evidence Tables for further information.

Caring

Good

Updated 13 February 2019

We rated the practice and all of the population groups as good for providing caring services.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • We observed that members of staff were courteous and helpful to patients and treated them with respect.
  • Feedback from patients we spoke with was positive about the way staff treated them.
  • We made CQC patient comments cards available prior to our visit. We received 19 completed comments cards. All of these included very positive feedback from patients about how they were treated.
  • Feedback from the national GP patient survey showed that the practice had received scores that were comparable to local and national average scores for patients feeling they were treated with care and concern.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about their care and treatment.

  • Patients told us they felt listened to and included in decisions about their care and treatment.
  • Results from the national GP patient survey for questions about patient involvement in planning and making decisions about their care and treatment were comparable to local and national averages.
  • Staff demonstrated a patient centred approach to their work during our discussions with them.
  • The provider was aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information they are given).
  • Interpretation services were available for patients who did not have English as a first language.

The practice had coded patients who they knew were carers on the patient record system and there was a range of information available to inform carers of the local support services.

Privacy and dignity

The practice respected and promoted patients’ privacy and dignity.

  • Staff recognised the importance of patients’ dignity and respect and they worked to ensure they maintained patient confidentiality.
  • Reception staff could offer patients a private area if they wanted to discuss sensitive issues or if they appeared uncomfortable or distressed.

Please refer to the Evidence Tables for further information.

Responsive

Good

Updated 13 February 2019

We rated the practice, and all of the population groups, as good for providing responsive services.

Responding to and meeting people’s needs

The practice organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider understood the needs of its patient population and tailored services in response to those needs.
  • Telephone consultations were available and this supported patients who were unable to attend the practice in person.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was co-ordinated with other services.
  • The clinical team provided home visits for patients with enhanced needs who found it difficult to attend the practice in person.
  • The premises were accessible and treatment rooms were available on the ground floor for patients who required this. The provider had made a number of improvements to the safety of the premises.

Older people:

  • Patients had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.

People with long-term conditions:

  • Patients with a long-term condition received an annual review to check their health and medicines needs were being appropriately met.
  • Patients with several long-term conditions were offered a single, longer appointment to avoid multiple visits to the surgery.

Families, children and young people:

  • There was a system to identify children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances.
  • A register of children at risk was in place and this was regularly reviewed and updated.
  • Babies and young children were offered an appointment as a priority and appointments were available outside of school hours.
  • The premises were suitable for children and babies and baby changing facilities were available.

Working age people (including those recently retired and students):

  • The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
  • Telephone consultations were provided and patients therefore did not always have to attend the practice in person.
  • The practice was proactive in offering online services including the booking of appointments and requests for repeat prescriptions. Electronic prescribing was also provided.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances for example those with a learning disability.
  • Same day appointments could be provided for patients whose circumstances made them vulnerable.
  • Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.
  • Longer appointments were available for patients with enhanced needs.

People experiencing poor mental health (including people with dementia):

  • The practice identified patients who experienced poor mental health in order to be responsive to their needs, for example by the provision of regular health checks.
  • Data showed that the practice was performing in comparison to and better than local and national averages for the care and treatment provided to patients experiencing poor mental health.
  • Patients experiencing poor mental health were referred to appropriate services such as psychiatry and counselling services and were informed about how to access various support groups and voluntary organisations.

Timely access to care and treatment

The provider had systems in place to closely monitor capacity and demand and utilisation of clinical appointments.

  • Patients with the most urgent needs had their care and treatment prioritised.

  • Feedback we received from patients was that they had seen improvements in access to appointments.
  • Results from the national GP patient survey showed that the practice had received scores that were similar to those of the Clinical Commissioning Group (CCG) and national averages for questions about access and people’s experience of making an appointment. However they received lower than average scores for getting through to the practice by phone. The practice manager was aware of this and the provider was intending to change the phone system to improve patient experience. The survey was carried out between January and March 2018.

Listening and learning from concerns and complaints

A system was in place for receiving, investigating and acting on complaints.

  • A complaints policy and procedure was in place.
  • A complaints information leaflet was available to help patients understand the complaints procedure and how they could expect their complaint to be dealt with.
  • We viewed a sample of complaints and could see what the outcome of the investigation was and that there had been learning from complaints.
  • Complaints were generally investigated at a practice level but they were all reported through a central reporting system and the provider had clear oversight regarding the nature of complaints, the outcome of investigations, lessons learnt and actions taken to improve patient care and experience.
  • Staff had been invited to attend workshops to look at their roles and responsibilities for managing complaints.
  • We saw examples of the duty of candour being applied in the management of complaints.
  • All complaint responses were signed off as agreed by the Chief Executive of the organisation.

Please refer to the Evidence Tables for further information.

Well-led

Good

Updated 13 February 2019

We rated the practice and all of the population groups as good for providing a well-led service.

Leadership capacity and capability

The provider had oversight of the service provided and leaders provided direction to the practice.

  • There was oversight of the systems and processes in place at the practice to ensure these were safe and effective. Some of the systems had been recently introduced and were still embedding.
  • Leaders were knowledgeable about issues and priorities relating to the provision of good quality services and the provider understood the challenges to the service.
  • Staff told us they felt leaders were visible and approachable and listened to their views.
  • Staff told us they felt listened to and well supported to develop their skills. Staff underwent an induction and periodic review of their performance.

Vision and strategy

The practice had a vision and strategy to deliver good quality care.

  • There was a clear vision and set of values.
  • The strategy was in line with health and social priorities across the region.
  • The practice planned its services to meet the needs of the practice patient population.

Culture

The practice had a culture of high-quality sustainable care.

  • Staff told us they felt well supported and valued.
  • Leaders and staff demonstrated a patient centred focus to their work during our discussions with them.
  • The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • Staff told us there were positive relationships across the staff team.

Governance arrangements

Systems of accountability and governance were in place.

  • Structures, processes and systems to support governance were set out. Some of these had been introduced more recently and had not been fully implemented or embedded at the time of this inspection. For example, provider level oversight of; performance data, medicines management and health safety related checks.
  • Data showed that the practice was performing similar to other practices locally and nationally for the care and treatment provided to patients.
  • Clinical staff used evidence based guidance in the treatment of patients.
  • Audits were carried out to evaluate the operation of the service and the care and treatment provided and to improve outcomes for patients.
  • The clinical system was used effectively to ensure patients received the care and treatment they required.
  • The system for reporting and managing significant events and incidents was effective and we saw examples whereby the learning gained from the investigation of events had been used to drive improvements.
  • Records showed that meetings were carried out to improve the service and patient care.
  • Practice specific policies and standard operating procedures were available to all staff and staff we spoke with knew how to access these.
  • The provider had introduced a system for monitoring health and safety checks across all of the primary care locations.

Managing risks, issues and performance

Systems were in place for managing risks, issues and performance.

  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was evidence of action having been taken to change practice and improve quality in response to the findings of audits.
  • A business continuity plan was in place to deal with unforeseen emergencies.
  • A system was in place for managing patient safety alerts and for ensuring appropriate action was taken in response.
  • Staff appraisals were provided annually and these were up to date across the staff team.
  • The practice had a risk register and this fed into the overarching provider risk register.
  • Performance meetings were held by leads within the organisation to review performance, risks and the plans to mitigate these.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Information technology systems were used to monitor and improve the quality of care provided.
  • There were appropriate arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The practice involved patients, staff and external partners in the delivery of services.

  • The practice valued feedback from patients and acted upon this.
  • The practice had an engaged Patient Participation Group (PPG). We met with one member of the PPG. They told us they had regular meetings with the practice and they felt their views were listened to.
  • Meetings were taking place for staff to raise issues and suggest improvements.
  • A staff survey had been carried out and the results of staff feedback had been analysed and published in July 2018.
  • The provider had knowledge of and incorporated local and national objectives.
  • The provider worked alongside commissioners, partner agencies and other practices to improve and develop the primary care provided to patients in the locality.

Continuous improvement and innovation

There was evidence of systems and processes for learning, improvement and innovation being in place or planned for the future.

  • There was a focus on learning and improvement within the practice.
  • Staff were involved in discussions about how to develop the service and encouraged to provide feedback about the service through a system of staff meetings.
  • The provider investigated incidents and used the learning from these to make improvements to the service.
  • The provider was working on a strategy for providing innovative models of care involving a multi-disciplinary approach to service provision.
  • The provider was in discussion with commissioners and other stake holders looking at maximising opportunities for improving the estates.
  • The provider was working alongside a secondary care provider with a view to introducing a behavioural therapist to support patients with mental health support needs.

Please refer to the Evidence Tables for further information.

Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good