Castlegate & Derwent Surgery

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• 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 has changed to inadequate.

This service scored 38 (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 did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

People were not involved in any assessment of their needs. Some staff were aware of the needs of the local community for example it was highlight that farmers were an at risk group due to the isolated area in which they live. Staffing challenges meant that clinicians did not have time to assess the needs of patients beyond the presenting complaint. This demonstrated a lack of holistic care. This meant that potentially undiagnosed conditions would be missed. Staff were under pressure due to the number of patients waiting to be seen. There was a lack of continuity of care, for example one clinician had documented a plan for a patient, which included a return appointment if symptoms did not improve. This was not actioned and this patient had to wait 4 weeks to be seen again.

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. Some clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. We noted some documentation did not include patient preferences. We saw evidence that medication reviews were coded but had not taken place. Leaders told us this was due to a computer system issue. We will review medication reviews at our next inspection. The triage system for patients that was in place at the time of our inspection did not provide assurance that protected characteristics were considered.

People’s needs were not always assessed using the appropriate range of assessment tools. Tools were not always used correctly or appropriately. For example, medication reviews. We also saw triage forms which incomplete information. People were not signposted appropriately whilst waiting for an appointment.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. We saw positive examples of social prescribing.

The service did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Systems were not in place to ensure staff were up to date with evidence-based guidance and legislation. We saw examples of reviews of patients being overdue in terms of recognised best practice and expected standards. In some cases this was up to 4 years. Prescribing best practice was not followed.

Leaders acknowledged that being short staffed, had led to challenges in recruitment, which had led to short falls in certain elements such as audit and quality improvement.

The provider did not always share their assessment of people’s needs when moving between different services. The service was inconsistent with how care was planned and co-ordinated. Communication with an external patient triage provider was not sufficient to keep patients safe, or ensure care was provided in a timely and effective manner. We reviewed evidence which indicated the practice did not utilise local services effectively; for example, a walk-in contraceptive clinic that patients could have been signposted to, but were not.

Staff had some 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. We spoke to local care homes who told us they felt patients received the care they needed; usually from a paramedic.

The service did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. The service did not always support people to live healthier lives, or where possible, reduce their future needs for care and support. Carers were coded on Emis.

Patients were not always involved in reviewing their health, and those who had been were not being reviewed as frequently as they should have been. We reviewed evidence which indicated the system that recalled patients was not effective. There was not a consistent approach to ensuring patients were supported and encouraged to maintain their own health. Due to patient demand, clinicians were not always able to utilise health promotion opportunities.

We reviewed evidence that indicated reviews carried out by nursing staff were effective. Nurses were completing long term condition reviews, and providing health advice. We note that the diabetic lead continued to hold an exercise class within the practice which received positive feedback. Smoking cessation was avaliable locally.

The service did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. The monitoring of patients was not effective. We noted that numerous groups of patients were consistently overdue for reviews, such as those awaiting prostate specific antigen (PSA) monitoring this is used to detect or monitor risk of prostate health, it is crucial to patients with or who are at higher risk of prostate cancer. Clinical leaders told us this was due to administration issues. It is unclear which patients we reviewed were overdue within the practice, or whom were treated by secondary care. Clinical leaders were not documenting this in patient notes. We also note patients requiring blood pressure monitoring for contraception were not reviewed in a timely manner.

The practice met national targets for cervical screening and immunisations.

From the clinical notes we reviewed, we found that people were not receiving reviews in line with current guidance. This had been raised by staff to leaders with no improvement plan identified.

Patients who were awaiting re-call for diagnostics such as x-rays were noted to be in a backlogged system. Clinicians had attempted to raise this with partners but had been ignored. Some patients had been waiting in excess of 5 years.

The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment. We reviewed records of consultations whereby it was not clear from the records if patients had been offered a chaperone. We also saw evidence which indicated staff lone working when running clinics where chaperones should have been offered and could not be.

Staff understood and applied legislation relating to consent. Capacity and consent were not always clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.