Bartholomew Medical Group

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. Searches identified that not all patients who had experienced an exacerbation of asthma were followed up within the correct timescale. Patients with Chronic Kidney Disease (CKD) did not always receive the required monitoring. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving between services. Staff made sure people understood their care and treatment to enable them to give informed consent. The practice had strong links with community services through their social prescriber. We saw examples of how these links had resulted in patients’ needs being identified and positive outcomes had been achieved. Staff involved those important to people to make decisions in people’s best interests where they did not have capacity. Patients with learning disabilities had been identified and the practice had completed the majority of reviews of the patients that were eligible for them.

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 always made sure people’s care and treatment was effective by thoroughly 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. 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. We found that the practice utilised a social prescriber wherever possible. They had developed their role to ensure that patients received maximum support. We saw examples of where support from a social prescriber had had a positive impact on patients, this included patients who were identified that would benefit from funding for things like new boilers as they had no hot water and a visually impaired patient who was given specialist equipment for their home. Social prescribers at the practice also ran a bereavement walk every month which was popular with patients.

The practice ensured patients with a learning disability received annual health checks. They had completed 123 of their 132 patients with a learning disability for a health assessment in the last 12 months.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. However, searches on the practices clinical system identified 64 patients that had been prescribed 2 or more courses of rescue steroids from 1,559 patients. We looked in detail at 5 patient and saw that 3 of the 5 patients had not been followed up within the correct timescale.

Searches also identified 11 patients with chronic kidney disease (CKD) 4 or 5 who had not received the correct monitoring in the last 9 months. We looked in detail at 5 patient records, 2 patients were under review of secondary care. The 3 other patients were not being monitored effectively. When this was fed back to the provider an action plan was put in place to rectify this. Administration staff were informed and started booking patients in for monitoring.

The practice had an audit programme to monitor the standard of care being delivered. We saw how outcomes of audits were shared in clinical meetings and actions for improvement were recorded and implemented.

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 provider held regular staff meetings which were used to share any changes across the practice. Through staff questionnaires, some staff reported that communication between different teams could be improved. As part of our site visit, we observed a huddle within the reception team which also included some clinical members of staff, where any updates and changes were communicated to the team. This had been implemented following staff feedback as a way to improve communication within the team.

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.

Staff had lead roles in areas including diabetes and asthma and worked closely with community teams to support patients. The practice was able to support patients accessing tier 3 weight management services. Tier 3 weight management service provides specialist support for people living with obesity.

We received positive feedback from patients regarding how positive and supportive staff were. They said, “the practitioners I have seen are always helpful and supportive.”

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.

We found that the practice was constantly striving to meet national targets for screening and immunisations, however due to their patient cohort they had struggled to achieve these for cervical cancer screening. The national target for cervical screening coverage is 80%. The most recent data (2024) showed the practice had achieved 65.4% for the number of women aged 25-49 and 65.1% for women aged 50-64 who had had a screening test within the last 3 and a half years. The practice had identified a cohort of patients that did not want to receive this screening, they had tried numerous ways to improve take up, this included target phone calls and supplying specific information on the benefits of receiving this screening. We reviewed the current figures for this current year, and they were both above the 80% target.

The national target for routine childhood vaccinations is 90% coverage. The World Health Organisation (WHO) recommends a rate of 95% for all routine childhood vaccinations. Those practices achieving this level are considered an example of good practice. The most recent data (2023/24) showed the practice had exceeded 95% in 4 of 5 routine childhood vaccination age groups and 93.2% in the other.

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 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 were appropriate and were made in line with relevant legislation.