Goodheart 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

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. Although there were areas for improvement in relation to coding patients records effectively, assessment records for patients with asthma prescribed steroids and do not attempt cardiopulmonary resuscitation (DNACPR) records immediate action was taken by the provider to address these areas.

This service scored 79 (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 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. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The provider had systems to identify people with previously undiagnosed conditions. However, our clinical searches identified 29 patients with a potential missed diagnosis of diabetes. A review of 4 of these patients showed they had had monitoring checks and annual reviews, but they had not been coded as diabetic for borderline diabetes. We were unable to assess what the coding history was for diabetes on the patient record system as there was no easily visible read code journal. The read code journal should be easily visible on the patient record system to facilitate review by any clinician. The manager told us the journal was usually visible and would review with the GP why it wasn’t in their case and address this. Following the assessment the provider submitted an action plan which showed actions taken to address findings. Actions included contacting patients for a review and repeat blood tests and reviewing and monitoring coding. Clinicians had been advised of findings and coding in a clinical meeting.

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 mostly provided in line with current guidance. For example, patients with diabetes were well managed with annual diabetic and medicines reviews completed.

Our clinical searches identified that more detail was required in assessment records for patients with asthma who were being prescribed rescue steroids to ensure safe prescribing, and one patient required a steroid card issuing as they had more than two issues for steroids. Following the assessment the provider submitted an action plan which showed actions taken to address findings. Actions included a review of asthma management and steroid care guidelines in a clinical meeting.

4% (8) of patients with hypothyroidism had not had thyroid function tests (TFT) monitoring for 18 months but a review of 2 patients showed that there had been oversight, and they had been contacted for monitoring tests. Following the assessment the provider submitted an action plan which showed actions taken to address findings. Actions included reinviting patients for blood tests and discussion of findings in a clinical meeting.

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.

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.

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.

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 practice was proactive in encouraging uptake of cervical smears and childhood immunisations and sent invitations by multiple routes including text messaging, letters and telephone. They had been involved with PCN initiatives including annual cervical smear week campaigns and undertaken poster and social media campaigns using NHS leaflets. They had commenced a project for the nurse to contact all patients who were overdue a cervical smear to offer counselling and to try to build up a relationship with the patient. They had also completed an outreach project where care coordinators contacted all families and explained value of immunisations.

The most recent data held by CQC for childhood immunisations (April 2023 to March 2024) showed the practice met national targets in all 5 areas measured and exceeded the World Health Organisation (WHO) target of 95% completion in 4 of 5 areas. They had consistently performed at this level since at least 2016. The most recent available data (June 2023) held by CQC for the percentage of persons eligible for cervical cancer screening who were screened adequately within 3.5 years for persons aged 25 to 49, and within 5.5 years for persons aged 50 to 64 showed the practice had achieved 76.8%, the target being 80%. The practice had consistently achieved within the high 70% - 80% for at least the last 9 years.

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 and relevant training had been provided. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. A review of 3 patients records where a DNACPR decision had been made showed detailed records of the consultation and the decisions made. However, only 1 patient record had the completed DNACPR form attached. The manager had identified this and told us the completed forms had been left with the patients at their home. They provided evidence they had requested that the forms were brought to the practice by the PCN clinician completing these so the record could be scanned onto the patients notes.