Favell Plus Surgery

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• 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 assessed all the quality statements from this key question. We looked for evidence that staff involved people in decisions about their care and treatment and provided them with advice and support. This key question has been rated as Good. We found staff involved people in decisions about their care and treatment and provided them with advice and support. Staff regularly reviewed people’s care and worked with other services to achieve 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 practice 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 practice was positive. People felt involved in the assessment of their healthcare needs and felt confident that staff also understood their individual and cultural needs. Feedback from people using the practice was positive. Leaders and staff told us the practice used codes and alerts on the patient’s record to highlight special needs and requirements. 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 practice 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.

The practice 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. Our clinical record searches found patients were receiving safe management and monitoring for medicines within the advised time frame. For instance, all monitoring of people with Asthma, Diabetes, Chronic Kidney Disease and Hypothyroidism was carried out in-line with current guidance. Leaders informed us they put in place protocols and systems processes to effectively manage this. There was evidence that patients who did not respond to invitations for reviews or failed to attend appointments continued to be monitored by the practice. Our searches identified one patient who was potentially at risk of having undiagnosed diabetes. During discussions with the practice team, they advised the patient had also been identified by them the day before our searches were run and they had developed a plan to support the patient.

The practice held registers for patients and provided annual health checks for those with learning disabilities, carers, people with severe mental health conditions and palliative patients.

The practice 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 practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. The processes in place enabled staff to liaise regularly with community teams such as community nurses, health visitors, and palliative care nurses. Staff told us regular multi-disciplinary team meetings were held with external agencies where vulnerable people were discussed and actions recorded. The practice regularly discussed patients receiving end-of-life care.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. The practice supported people to live healthier lives and where possible, reduce their future needs for care. Staff focused on identifying risks to people’s health, including those who are (or might be) vulnerable such 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 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.

The practice did not meet national targets for screening and immunisations (the World Health Organisation (WHO) standard of 95% achievement). However, staff demonstrated efforts made to increase uptake of immunisations amongst its patient population and systems in place to try and reduced failed attendance. 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 practice told people about their rights around consent and respected these when delivering person-centred care and treatment. People we spoke with and the evidence we reviewed did not raise any concerns around consent. People understood their rights about consent to the care and treatment they were offered Clinicians understood the requirements of legislation and guidance when considering consent. Clinicians supported people to make decisions ensuring their views and wishes were considered during care planning. Assessments of mental capacity were carried out when needed and were decision specific. Staff told us they were able to adapt or translate information about care and treatment so that people could understand, to support them making informed decisions. All staff we spoke with were able to discuss how to gain informed consent for treatment. We saw that consent was documented and processes were in place for chaperones to be present if requested.

We reviewed a random sample of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms and found information on these was not always readily available. (The ReSPECT form is a tool for documenting patient preferences regarding care at the end of life, ensuring that their wishes are respected in emergency situations). We discussed this with the leadership team who advised this was an area in need of improvement and there had been some confusion on the use of digital read coding in the practice’s computer system to readily identify these patients.