South Grange Medical Group Practice Also known as South Grange Medical 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, and that staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key as Good. At this assessment, the rating remained as Good.

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 provider made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had systems to identify people with undiagnosed conditions, and staff described how they used appointments to opportunistically consider the wider health needs of patients.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. The percentage of respondents to the latest national GP patient survey who stated that during their last appointment they were involved as much as they wanted to be in decisions about their care and treatment was 96%, above the national average of 91%.

Staff were aware of the needs of the local community. They 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.

Relevant information was routinely shared with other professionals when planning care and treatment, and patient records were updated promptly to reflect any changes. The provider had systems in place to identify patients with potentially undiagnosed conditions, such as diabetes or cancer.

Those living with long-term conditions or learning disabilities were invited for regular reviews and given appropriate follow up information and signposting. Our clinical searches showed that patients with long term conditions such as diabetes and asthma were appropriately monitored and followed up.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation, which included peer reviews, appraisals, regular clinical training reviews, time-out sessions, and access to training and development to enable staff to feel confident in their roles.

A remote review of the patient record system showed that patients received appropriate long-term condition reviews.

The provider worked well across teams and services to support people.

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 transferred to other services such as community nursing. Staff highlighted good communication within the practice.

For patients with the most complex needs, the GPs worked with other health and care professionals such as district nurses to deliver a coordinated package of care.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.Clinical staff made referrals to educational programmes for weight management and diabetes. All patients with a learning disability had been offered their annual health check, with an 85% take-up rate.

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. The practice had proactively and successfully identified carers within their practice population, who they were then able to offer additional support, services and signposting to. Some staff had undertaken extra ‘Carer Awareness’ training and there were identified Carers Champions within the practice.

Staff proactively supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. Clinicians discussed health promotion and social prescribing during appointments and opportunistically looked to book cervical screening appointments or other tests where possible.

The provider routinely monitored people’s care and treatment and had processes in place to monitor results and referrals.

The practice was below both cervical screening indicators (for younger and older populations) at 75.2% and 73.4%, slightly below the national target for both of 80%.

The practice invited patients routinely and opportunistically to cervical screening and proactively called patients who were overdue for screening tests. The practice offered a range of appointments to patients as well as Enhanced Access appointments at weekends at different surgeries through local commissioning arrangements.

The practice had successfully met or exceeded the 90% minimum uptake target rates for all childhood immunisations, showing that systems for invite and reminders were working well. Data shows that childhood immunisation rates in more deprived areas tend to be consistently lower, so this was notable given the deprivation levels of the practice population.

The practice had a good understanding of barriers their patients faced in care planning and preventative health care, including digital exclusion and communication difficulties, and tried to work to reduce these.

The practice had a programme of clinical audit and quality improvement initiatives, and these were used to improve patient outcomes. For instance, increasing the proportion of patients receiving correct levels of oral iron medication where they required it, and increasing bone scans where required for patients at risk of osteoporosis.

The provider 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 had received appropriate training. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation with documented discussion.