West Common Lane Teaching 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

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. When a patient did not have capacity, staff involved people important to the patient to ensure that decisions were made in their best interests.

This service scored 71 (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 mostly positive. People felt involved in any assessment of their needs and were 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. 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.

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.

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 had effective systems in place to identify and monitor patients with long-term conditions, as well as those prescribed medicines requiring regular monitoring. For example, our clinical searches identified that 73 of the 585 patients diagnosed with diabetes had a HbA1C (blood test to check glucose levels) above 75 mmol. We reviewed 3 records, and all had actively been followed up. The systems in place supported the timely recall, review, and ongoing monitoring of patients with long-term conditions at appropriate intervals.

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.

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. For example, they carried out routine NHS health checks on eligible patients.

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 clinical searches we carried out confirmed that patients with long term conditions or those on high-risk medicines that required monitoring were actively reviewed and followed up and were receiving treatment in line with national guidelines. From the clinical notes we reviewed and the clinical searches we carried out, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

However, performance data indicated that the practice was below the national target of 80% for cervical screening, with the most recently published data showing that 68.8% of eligible patients in the 25 to 49 year age group having had an adequate screening test in the last 3.5 years, and 76.1% of eligible patients in the 50 to 64 year age group having had an adequate screening test in the last 5.5 years. In addition, they were also below the 90% minimum target for 3 of 5 childhood immunisations.

In response to this, the provider reported that there was a process in place whereby practice nurses actively contacted patients who did not attend for immunisations and liaised with health visitors where appropriate. They also highlighted that they had used their social media platform to educate patients on the increase in measles cases, that they had retained a member of their clinical team to improve the availability of cervical screening appointments and that staff were proactively contacting patients who were due or overdue screening.

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 we reviewed were appropriate and were made in line with relevant legislation.