Bridgeway 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

We looked for evidence that staff involved people in decisions about their care and treatment and provided them with 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. This meant people’s outcomes were good, and people’s feedback confirmed this.

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 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. Digital flags within the care records system were used 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. For example, people whose blood tests results showed they had pre-diabetes were offered appointments to advise them how they could prevent it developing into diabetes. Our remote clinical searches found one patient whose blood tests required follow up as they indicated they may have diabetes. Whilst the patient had been notified, they did not engage with the practice who continued to contact them regularly to encourage them to attend an appointment.

People’s care and treatment was planned and delivered and people were involved in decisions about their care, including what was important and mattered to them, for example, end of life care. This was done 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 mostly demonstrated care was provided in line with current guidance.

The service 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. Staff feedback was generally positive about how they worked together with the service. For example, there was team working across different staff groups to address issues such as follow up of people who failed to attend important appointments. The service worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. People had access to services provided by the primary care network (PCN), including physiotherapy, social prescribers and extended access appointments. Mutual support and learning were shared across the PCN.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service routinely monitored people’s care and treatment to continuously improve it. The service did not meet national targets for screening and immunisations. National data showed all 5 indicators for childhood immunisations were consistently below the 95% World Health Organisation based target for uptake over time. Uptake of cervical smears was below the national target of 80% and this had been consistent over time. Leaders expressed ongoing challenges to achieve higher uptake rates because of their transient population who lived in the area temporarily or declined because they had obtained vaccinations from other countries. However, they offered flexible appointments, including home visits for vaccination if preferred. The service had systems in place to monitor attendance and follow up non-attenders. Smear reminders were sent on pink coloured paper and people who refused screening were informed they would be sent reminders in case they changed their views. The service engaged in audits and quality improvement. Whilst there were continued challenges with uptake of vaccinations and immunisations, the practice nurse was recently commended by a local pilot for steps taken to encourage and improve vaccination uptake from the local population and was asked to write a paper on this to share with other practices.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. The practice kept records of lasting power of attorney and consent to treatment forms were in place where people had mental capacity. We reviewed three records which showed Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.