Amherst 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. However, improvements were required.

Following our clinical searches, the provider sent us evidence of improvements they were intending to make in response to our findings. For example, implementing an action plan to review the clinical records of people identified and take further clinical action (where required).

We will review these improvements at our next assessment.

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 were effective. They appropriately checked and discussed people’s health and care 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. 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 checked people’s health, care, and wellbeing needs during health reviews. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. We saw evidence of audits of social prescribing, which showed positive outcomes for people.

As part of our assessment a number of set clinical record searches were undertaken by a CQC GP Specialist Advisor. These search criteria are freely available for practices to access at any time. The provider had systems to identify people with previously undiagnosed conditions. However, improvements were required. We identified during the clinical searches that 108 people were at risk of being missed as diagnosed with chronic kidney disease. Following our clinical searches, the provider sent us evidence of an action plan they had implemented in response to our findings. This included a realistic date for completion and showed that several clinical records had already been reviewed as part of this.

The service always 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. They worked to develop evidence-based good practice and standards.

As part of our assessment a number of set clinical record searches were undertaken by a CQC GP Specialist Advisor. These search criteria are freely available for practices to access at any time.

Clinical staff had access to relevant national and local guidelines and used this information to help ensure that people's needs were met.

Staff told us they received regular updates from leaders at the service. Where there were changes in process guided by learning at the service, staff told us that they were informed and involved in implementing changes.

Staff were aware of the need to complete accurate and full records, such that information did not need to be repeated by patients.

Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. Care and treatment for patients in vulnerable circumstances was coordinated with other services. There were established pathways for staff to follow to ensure patients’ needs were met.There was no feedback of concern in relation to how staff, teams and other services worked together from partner organisations.The service ensured that care was delivered in a coordinated way and took into account the needs of different patients, including those who may be vulnerable because of their circumstances.

There were clear and effective arrangements for booking appointments and transfers to other services.

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. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The service 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 met national targets for screening. The practice had higher than average national targets for childhood immunisations. Leaders told us that improving the uptake of childhood immunisations, was discussed at monthly clinical meetings and had been subject to a survey conducted by the patient participation group (PPG).

Leaders and staff told us that audits were discussed at clinical meetings; this was confirmed in the minutes of the meetings we reviewed.

The provider submitted clinical and management audits. These covered medicines, health condition and mental health/well-being monitoring, which they had carried out to improve outcomes for patients. Leaders held regular clinical and all staff meetings which monitored patients’ outcomes, where the findings were shared.

Patients did not raise any concerns regarding the practice seeking their consent to care and treatment.

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

Consent documentation in relation to minor procedures was appropriately recorded and documented.

Relevant staff had been provided with training in the Mental Capacity Act. The service monitored the process for seeking consent appropriately and patient record searches demonstrated that consent was recorded appropriately. We reviewed Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions for 3 people and found they were not always maintained in line with relevant legislation. Following the site visit, the provider sent us evidence to show they had implemented a standard operating procedure for Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), to ensure a consistent approach. We will review this at our next assessment.