Rockliffe Court Surgery

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 based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity.

This service scored 75 (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 extremely 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. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff told us the practice was a hub of the community and demonstrated signposting patients who were vulnerable or needed extra support.

Staff checked people’s health, care, and wellbeing needs during health reviews and we reviewed evidence of staff taking time to establish what was important to the patient. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. 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, to a social prescriber. Staff across the practice had a good understanding of the patient population.

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. Clinical and non-clinical teams had a knowledge of external support service for these groups of patients and did this in line with legislation.

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 practice demonstrated a robust system for notifying staff of patient safety alerts and they were actioned in a timely manner. Clinical searches carried out as part of our inspection demonstrated a comprehensive recall system. Medication reviews were conducted within the practice in a timely manner. All patients we noted as ‘overdue’ for review had been contacted by the practice, and documentation clearly outlined reasons why this group of patients may not have attended. There was a comprehensive process in place for staff to follow in relation to medication being prescribed to patients if a review was overdue. This was communicated with the patient via text message. Patients with an active Do Not Attempt Cardiac Pulmonary Resuscitation (DNACPR) were up to date, clearly documented and shared appropriately.

The service always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

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 practice held a daily huddle which discussed vulnerable patients, share examples of good practice and provide support to one another if it was required. The practice had patients who lived in local care homes. Staff were aware of these patients and ensured care was delivered to them in a timely manner. The practice utilised their Patient Participation Group (PPG). The PPG told us when issues or suggestions were brought to the practice they were listened to and resolved promptly. There were regular meetings.

The service always supported people to manage their health and wellbeing to fully 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 focused 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. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. Staff took opportunities to speak to patients regarding health promotion at the time of consultation. Where required patients could request a longer appointment. All staff within the practice utilised care navigation or social prescribing. The practice had an awareness of what was important to the population and had implemented a clinic with a PCN physiotherapist to prevent delays in waiting times. The practice had also run specialist sessions online to deliver education around the importance of dietary changes for patients who were coded as pre-diabetic.

The service monitored all people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

The practice had met national targets, for cervical screening. For women under the age of 49 the practice had achieved 85% coverage with a target of 80%. For women aged over 50, the practice had achieved 87% coverage against a target of 80%. Furthermore, childhood immunisations were all achieving target coverage at the time of our site visit. The practice had been approached by the local Integrated Care Board (ICB) to share learning on how the practice had achieved these targets.

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. Clinicians were enthusiastic about quality improvement and strived to ensure all patients received the best outcomes. We reviewed audits which clearly demonstrated improvement for patients. The leadership had considered the needs of the local population and community.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. Documentation we reviewed demonstrated that staff understood how to document capacity. 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. Staff were aware of best interest decisions and power of attorney. All training related to capacity and consent was up to date.