Middleton Health 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

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 outstanding. At this assessment, the rating remains the same.

This service scored 88 (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 always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them. All staff were centred on people as individuals, and went above and beyond to ensure individuals needs were considered and met.
Feedback from people using the service was positive, the GP patient survey showed that 82% of respondents said the healthcare professional they saw or spoke to was good at considering their mental wellbeing during their last general practice appointment, compared to the national average of 54%. 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, and that the practice sits in a high deprivation area, and the needs that are presented with this patient group. 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 holistic health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing.
The provider had effective systems in place to identify people with previously undiagnosed conditions and to proactively support those who may not be engaging with healthcare services. This included the use of a dedicated ‘missingness’ programme, through which staff actively identified patients who had not attended the practice within a specified timeframe or had not participated in recommended health checks and reviews. The practice took a proactive and holistic approach to assessing people’s needs, including visiting patients in their own homes to better understand any barriers they faced, build trusting relationships, and gain a comprehensive understanding of their individual circumstances and support needs. This proactive approach enabled the practice to reach out to patients, encourage engagement with services, and help ensure that potential health needs were identified and addressed.
The practice made effective use of the social prescribing services available within the Primary Care Network (PCN) to support patients with a range of non-clinical needs. In addition, the practice had embedded a focused care worker who managed their own caseload and provided enhanced, personalised support to patients, helping to ensure that those with more complex needs received coordinated and ongoing care. The focussed care worker on average provided person centred care to around 125 households per year. Approximately 25% of those being of lower complexity, typically assessed and discharged within 3 months. A further 50% were of moderate complexity and received support for between 3 and 9 months. The remaining 25% were people with higher complexity of need, receiving support for 9 months or longer. Feedback from patients who had intervention from the focussed care worker were all positive, and 100% of patients who gave feedback advised they would recommend this service to others for support if required.
 

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.
Systems were in place to ensure staff remained up to date with current evidence-based guidance, best practice recommendations, and relevant legislation. Staff were supported to access training and updates appropriate to their role, and clinical records we reviewed demonstrated that care and treatment were delivered in line with current national guidance and recognised standards of practice.
 

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 practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.
There was a fully collaborative approach to planning and coordinating people’s care across the whole team from the point of access with reception team to clinicians and the focused care worker, enabling a holistic package of care for people, fully reflecting individual circumstances and preferences. The team also worked with other local partners to establish pathways to refer into other community organisation and primary care network.
There was a clear ethos of working collaboratively and staff and teams had found innovative and efficient ways to deliver more joined-up care and support to people, from working one to one with a focused care worker or referring into specialised programmes such as recoffery project and the low carb group.
We found evidence that regular meetings were held across the service, including clinical, nursing, non-clinical, partner, safeguarding, quality, and safety meetings. These forums promoted effective engagement across the wider team and provided staff at all levels with opportunities to share their views and contribute to service development. The practice maintained strong and productive relationships with key stakeholders and partner practices within its Primary Care Network (PCN). It closely monitored secondary care data, proactively identifying gaps in local provision for example they had identified a link between patients voluntary discharging themselves from hospital and high mortality rates. As a result, they actively made contact with people on discharge to understand individual circumstance and how together with other health and social care partners they could support people to access and attend health care.
In addition, they actively monitored health inequalities data taking action to minimise associated risks to patients. The practice also played a proactive and influential role within the PCN, leading on both finance and health inequalities initiatives, while supporting the wider network through the delivery of training and development opportunities for other practices.
 

The service always supported people empowering them 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. Supporting people to live healthier lives integral part of the practice ethos with a strong culture of reducing health inequalities
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 through use of PCN social prescribers and the focused care worker. The practice demonstrated a strong commitment to meeting the needs of the LGBTQ+ community through a focused and inclusive approach to care. This included providing dedicated services for transgender patients, ensuring they had access to appropriate, person-centred support tailored to their individual needs. The service also holds the Gold accreditation in Pride in Practice. The service also provided a dedicated Recovery Support Group, ‘Recoffery’, which runs fortnightly for patients requiring support with alcohol and substance misuse, as well as those seeking to maintain sobriety. The group offered a supportive and non-judgemental environment where individuals could access guidance, peer support, and ongoing encouragement to help them achieve and sustain positive outcomes.
The practice also delivered a Low Carb Group, which provided patients with lifestyle and dietary support to help them make informed choices about their health and wellbeing, data showed that 83.3% of attendees successfully lost weight after the 6 week group, and 100% of attendees intended on carrying on the lifestyle. The group offered education, guidance, and encouragement to support healthier eating habits and lifestyle changes, particularly for those seeking to manage their weight or improve long-term health conditions. Where people needed more one to one support they could be referred to the focused care worker where an individualised care plan is developed, this could be in relation multiple lifestyle factors including reducing alcohol consumption and smoking cessation. Independent evaluation of the work carried out by focused care workers showed a positive impact in relation to and lifestyle changes. These initiative’s formed part of the practice’s wider approach to empowering people and promoting patient wellbeing and supporting individuals.
 

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.
Although the practice was not meeting all national targets for screening and immunisations, staff demonstrated a proactive and sustained commitment to improving uptake and achieving the required standards. A range of initiatives had been implemented to encourage patient engagement, including community-focused events such as a Halloween party designed to promote childhood immunisations. The practice also operated a well-established recall process, with a designated member of the administration team responsible for managing cervical screening and childhood immunisation recalls every Tuesday. This structured and consistent approach demonstrated the practice's ongoing efforts to improve screening and immunisation rates. 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 service always carefully explained to people what their rights around consent were, made sure they fully understood them and always fully respected these when delivering person-centred care and treatment.
Staff had a clear understanding and applied legislation relating to consent. Capacity and consent were clearly recorded. The practice actively promoted its chaperone service to patients, helping to ensure they were aware of the support available during consultations and examinations. All staff had received chaperone training, which was further enhanced through in house, face-to-face training delivered by GPs using real life scenarios. This training included guidance on obtaining and recognising valid patient consent, understanding professional boundaries, and fulfilling the responsibilities associated with the chaperone role. This comprehensive approach helped to strengthen staff knowledge and confidence, supporting the delivery of safe, respectful, and patient-centred care. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.