Longtown 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

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was usually based on evidence and good practice, although clinical audits were not formalised. Staff made sure people understood their care and treatment to enable them to give informed consent.

This service scored 67 (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 service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual needs. Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments.

The provider 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, within the Primary Care Network (PCN).

We did not receive any concerns from patients about the care and treatment they received at the practice.

However, the practice could not demonstrate that they fully completed searches or audits for clinical systems. This included reviewing coding of patients with long-term conditions or patients on multiple medications.

At the time of our assessment the practice were unable to demonstrate implementation of any audits at practice level being carried out on a formal basis using a two cycle process. We did review one audit that had been completed in relation to cholesterol using this formal process. We spoke with stakeholders in relation to audits initiated on a local level, they advised us that in 2024 the practice opted to carry these out. It is unclear if the pracitce has continued to revisit these audits. For the 2025 year the practice had declined to take part. Leaders told us they carry out numerous informal aduits, and do not intend to change this process they currently follow.

The clinical searches completed as part of the assessment noted a lack of review of patients on multiple medications and whether a PPI was appropriate. Leaders told us they would review all patients in this criterion. Following the assessment, it was confirmed to us that patients had been contacted and appropriate additional medications prescribed. The searches also raised issues around the correct coding of diabetic patients on clinical systems. Again, leaders told us this would be immediately addressed.

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. Leaders told us the practice does not routinely work in collaboration with the other GP practice within the PCN as they do not feel it is required.

The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The practice had an agreement in place to allow the Citizens Advice service to base themselves on site on certain days and allow patients to book appointments.

The provider had a GDPR (general data protection regulation) policy in place and safe processes for information sharing.

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.

There was some evidence that staff supported national priorities and initiatives to improve population health, for example, tackling obesity. Patients are actively provided with advice, medications (if deemed clinically necessary), and other digital support. Patients are also referred to weight management services, whilst continuously monitoring outcomes in house.

Other national priorities that were addressed by the practice included smoking where a weekly smoking cessation session was held. The practice also recently started a chair yoga group for patients particularly those that suffer from loneliness.

The practice has a recall system for patients particularly in relation to immunisations and vaccinations, with staff trained to provide advice and support to address patient concerns and clinicians provide personalised information. The practice also has a dedicated screening process for non-attenders especially for patients in relation to cancers including cervical, breast and bowel.

The practice told us they frequently post on social media regarding public health-related topics, screening programmes, immunisations and vaccinations, smoking, mental health, child and young person wellbeing and healthy self-care. The benefits of this were evidenced in the feedback we received from the PPG.

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. This they did particularly in relation to patients in local care homes and the practice had a carers’ register.

The practice has a social prescriber who focused on elderly patients and patients with mental health problems, learning disabilities and autism. Leaders told us social prescribing was done informally by all staff but there was no oversight of this from leadership, furthermore no examples of outcomes for patients were provided. The practice has also, PCN led, contracted with LINK workers (Bernardo’s) as a social prescribing service to support young people with mental health and wellbeing support.

During the site visit we spoke to leaders about a survey that was in the waiting room relating to loneliness. Leaders told us this had been an ICC (Integrated Care Community) led project and had finished. Records showed a decision had been taken that practice staff would not have time to complete the survey with patients, but to signpost them appropriately.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. This was evidenced by the lack of complete auditing cycles and the findings from the clinical searches. We reviewed evidence that clinical leaders were running regular searches however we were not assured that there was a continuous oversight of this process. The practice could not demonstrate that there had been positive outcomes for patients based on these searches.The practice has provided us with evidence that they have begun to review this process and make it more robust in order that it demonstrates clearly positive outcomes for patients in certain groups, such as those with COPD. We will review this at our next inspection to ensure it is embedded within the practice.

The most recent data from the UK Health Security Agency shows that for the period 2023 to 2024 the practice achieved 100% uptake for childhood (aged 2 and under) immunisations including the MMR vaccine and the Meningitis C booster vaccine. At the time of the assessment however, unverified data from the practice showed the uptake for the MMR vaccine for babies under 18 months was at 80% against a national target of 95%. Leaders were able to demonstrate the practice had a process in place to attempt to provide education for those patients who chose not to have a vaccination.

Data from NHS England from 2023 to 2024 shows that the practice achieved 79.5% against an 80% target rate for patients aged 50 to 64 years old having cervical cancer screening. The proportion of patients aged 25-49 years was at 78% against a target of 80% for cervical screening. The practice provided unverified data which showed in year they were on track to meet the screening target, for example, the proportion of women aged 25-49 who had been screened was 86%, and women aged 50-64 was 93%.

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, for example those patients who were on palliative care.

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.