Guidepost Medical Group

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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 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, we rated this key question as Good. At this assessment, the rating remains the same.

This service scored 63 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Score: 2
The service did not always make sure that people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing, and communication needs in partnership with them. People spoke positively about the support they received and felt involved in their assessments, with staff demonstrating an understanding of individual and cultural needs. Systems were in place to identify undiagnosed conditions, and patients could be referred for social support where needed.
However, our assessment also identified that systems were not consistently effective in identifying and managing patients’ needs. For example, there were some gaps in the timely diagnosis of conditions such as diabetes. We also found some weaknesses in the monitoring and oversight of high-risk conditions and medicines. This included inconsistent monitoring, incomplete clinical reviews, and poor follow-up arrangements at times.

Most of the time, the service planned and delivered people’s care in partnership with them, taking account of what mattered to individuals. Systems were in place to ensure staff remained up to date with evidence-based guidance and relevant legislation, and care was generally delivered in line with national standards, supported by appropriate assessment and clinical judgement.
However, there were occasions where the service did not fully follow National Institute for Health and Care Excellence (NICE) guidance. For example, we identified some poor management of asthma exacerbations, where care was not consistently evidence based. This included the prescribing of some incorrect steroid doses, insufficient clinical assessment of patients, and a lack of appropriate follow-up at times, in line with NICE guidance.
Guidance was not consistently followed for monitoring high-risk medicines, and there were missed opportunities to provide gastroprotection (such as PPIs) for older patients on NSAIDs or antiplatelet therapy.
These inconsistencies increased the risk of harm to patients and highlighted the need to strengthen systems, clinical oversight, and adherence to evidence-based guidance to ensure a safe and consistent approach to care.

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 practice tailored its approach to meet the needs of its local population. Link workers supported patients to access wider services, including mental health support and debt counselling, helping to address the wider determinants of health.
Support from the Primary Care Network (PCN), alongside additional roles such as a dedicated pharmacist, on-site physiotherapists, and access to advocacy services, enhanced patient care. The practice also hosted a Healthy Heart bus, which provided patients with health information, educational talks, and on-site checks such as weight and blood pressure monitoring.
Staff were proactive in identifying risks to patients’ health, including those in the last 12 months of life, individuals at risk of developing long-term conditions, and patients with caring responsibilities.

The service routinely monitored people’s care and treatment to improve outcomes. Systems were in place to support quality improvement through a structured audit programme. This included compulsory audits on repeat prescribing, diabetes and frailty, and chronic kidney disease (CKD) diagnosis, as well as additional audits such as Topiramate and Valproate safety and antidepressant prescribing.
Childhood immunisation uptake was strong and exceeded national targets. For example, 100% of children aged 1 had completed a primary course of vaccinations, compared to the World Health Organisation (WHO) target of 95%. In addition, 95.5% of children aged 2 had received 1 dose of the measles, mumps and rubella (MMR) vaccine, meeting the WHO recommended standard.
However, the practice did not meet all national screening targets. Cervical screening uptake was below the 80% target, with rates of 73.3% for patients aged 25 to 49 and 75.4% for those aged 50 to 64. The practice had systems in place to improve uptake, including recall and follow-up processes. Patients who did not attend were offered additional support, such as referral to health and wellbeing coaches or mental health practitioners where appropriate. For children, staff worked with health visitors to support engagement. A usual GP approach also helped promote a more personalised and consistent approach to care.

The service informed people of their rights in relation to consent and respected these when providing person centred care and treatment. During our assessment, we reviewed records relating to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. While DNACPR decisions had been recorded, supporting documentation such as capacity assessments and records of discussions were not consistently available in the sample reviewed. This meant we could not be assured that decisions were always made and reviewed in line with relevant legislation and guidance.