Dr Neeta Ghosh-Chowdhury Also known as Hilltop Medical 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 in April 2016, we rated this key question as Good. At this assessment, the rating remains the same because we found no issues with the effectiveness of assessing, monitoring and improving patient needs and care.

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. There were digital flags within the care records system to highlight any specific individual needs. 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. For example, 26 out of 30 health check reviews for patients with learning disabilities had been completed in the past year and documented from our review of the patient records. Patients with caring responsibilities were identified and 40 out of 56 carers health check reviews had been completed in the past year. Patients with caring responsibilities were referred to relevant support services where needed. The provider had effective systems to identify people with previously undiagnosed conditions. The service demonstrated awareness of Jess’s rule.

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.

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 had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The service worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. The service worked with local food banks and support services to ensure the needs of the patient population were met.

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. 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. The service supported their patients to enrol for online weight management programmes and uptake of gymnasium memberships.

The service routinely monitored people’s care and treatment to continuously improve it. They strove to ensure that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. Evidence we reviewed showed the practice is involved in patient monitoring processes with the Primary Care Network (PCN). For example the practice had completed 85% of health checks for learning disability patients, 71.4% carer’s health checks and from NHS England data, met the 80% target for cervical screening in those aged 50-64 years. However, the service had not met the remaining national targets for screening and immunisations. Latest published childhood immunisation uptake ranged between 58.4% and 89.9% which was below the 95% target, similarly cervical screening for those aged 25-49 was 65.5% which was below the 80% target. However, there service had a standard approach was a system of to recall and to educate the patients with the use of and language interpreters were used to support the patients who had declined who were non-takers to have an with their understanding of the health offers available. The impact of this action on the uptake was not yet known.

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. Our review of some DNACPR records confirmed this.