Christchurch Family 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 assessed all quality statements in the effective key question.

Staff actively involved patients in decisions about their care and treatment, offering appropriate advice and support. Care was regularly reviewed, and staff worked collaboratively with other services to ensure individual needs were met. Assessments considered patients’ communication, personal, and health requirements, with care delivered in line with current evidence and best practice. Partnership working with external agencies supported positive outcomes and smooth transitions between services. Patients were supported to understand their treatment and provide informed consent. Where individuals lacked capacity, staff involved those important to them in decisions made in their best interests.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed. This quality statement is rated Good

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.

Staff demonstrated an understanding of the additional support some patients may need when attending their appointment. For example,requiring a translator or involving a carer in assessing a patient’s treatment needs. Digital flags on individuals clinical records supported this. A dedicated care coordination team supported vulnerable patients with care and treatment needs and followed up on failed to attend appointments.Support to access online services was offered via text message and videos to patient phones, with step-by-step guidelines. Staff were aware of the needs of the local community.The Patient Assistant Team provided support to patients registering with the practice, acting as a first point of contact. They also monitored the carer register and identified opportunities to refer people to social prescribers (a service that connects people to activities, groups, and services in their community) to help improve health and wellbeing. The practice had undertaken a comprehensive study to improve the management of patients with long-term conditions (LTCs). It utilised Quality and Outcomes Framework (QOF) disease registers to analyse patient cohortsanddeveloped bespoke clinical searches and risk stratification tools to prioritise care based on clinical need. For example, the use of a red, amber, green rating (RAG) ensured that high-risk patients (red) were proactively invited for clinical reviews and lower-risk patients (green) received lifestyle advice and electronic messaging, ensuring efficient use of resources within the practice.Red cohort patients received urgent clinical reviews within 24–48 hours. Amber cohort patients were reviewed within two weeks. LTC pathways implemented following the study hadimproved patient safety and ensured appointment requirements for each LTC reduced unnecessary face-to-face appointments. This informed the development of a tailored workforce and appointment model, ensuring patients were booked with the most appropriate clinician. Follow-up appointments were introduced to support continuity of care, enhancing patient experience and outcomes. Multidisciplinary teams now work collaboratively across chronic disease areas. Nurses and clinical pharmacists delivered reviews jointly, supported by monthly team meetings. The practice had effective systems to identify people with previously undiagnosed conditions. We looked at the potential missed diagnosis of diabetes as part of our clinical searches. We sampled 5 patient records from 28253 patients and found that 1 of them was identified as pre-diabetic. Following the site visit, the provider took action to include this patient in the non-diabetic hyperglycaemia register to ensure they received annual invitations for diabetic screening blood tests in line with national guidance.

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.

Staff told us they received regular updates from leaders at the service. Where there were changes in processes guided by learning at the service, staff told us they were always informed, and relevant staff were involved in driving change. Evidence-based guidelines were discussed in governance and clinical meetings with minutes shared for all relevant staff. Staff told us that wherever possible they were given protected time to complete continuous professional development. The practice supported and encouraged clinical staff to pursue further training in their specific areas of interest. Our clinical searches showed the practice managed and monitored patients with long-term medical conditions including advanced stages of chronic kidney disease, corticosteroid use following asthma exacerbations and hypothyroidism in line with evidence-based national guidance.

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 described a positive working environment valuing strong team dynamics and the support of colleagues. They appreciated the collaborative nature of their roles and felt well supported by GPs and the leadership team, who were described as visible, approachable, and responsive to staff needs. All relevant staff at the service accessed the information they needed to understand people’s needs and appropriately assess, plan and deliver their care, treatment and support. The practice had established a dedicated clinical hub to enhance continuity of care and support complex case management. Feedback from partners indicated good working relationships with staff from the practice. Representatives from local care homes reported positive experiences of working with the practice. They stated the service was responsive, collaborative, and effectively met the needs of their residents, responding promptly to care requests and concerns. The practice worked collaboratively with their Patient Participation Group (PPG) who represented the views of people using the service, to improve patient’s experience. A representative of PPG commented that the level of medical care provided by the practice was exemplary.

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 identified 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 adopted a holistic and person-centred approach to care, which included the use of social prescribing. Patients were offered up to six individual sessions to explore what mattered most to their health and wellbeing. These sessions enabled patients to access a wide range of support, including local activities such as arts, gardening and creative groups, as well as assistance with housing, benefits, financial matters, employment, education and counselling.

Staff worked collaboratively and discussed patient care in clinical meetings, ensuring a joined-up approach to meeting care needs. The practice identified people who may require additional support and signposted them to appropriate services. The practice was responsive to the needs of its patients and had dedicated clinics led by clinicians with special interests in specific areas of care. These clinics were designed to deliver high-quality, focused clinical services tailored to individual patient needs. This approach supported early diagnosis, effective treatment, and ongoing management of long-term conditions.

The service routinely monitored people’s care and treatment to continuously improve it.

Staff ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. The practice met national targets for screening and immunisations. During our clinical searches, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. National data showed that all 5 indicators for childhood immunisations had achieved the 90% minimum uptake rate. Children who were not brought to appointments were followed up with contact made with their parent or carer. Latest national data (dated 30 June 2023) showed that 79.0% of eligible people had received cervical screening within a set timeframe compared to the national target of 80%.This data had been discussed at a GP learning event and recorded in meeting minutes. A new pilot project was starting with a focus to improve cervical screening uptake, mental health and women's health.

The practice has implemented a Two Week Wait (2WW) referral policy to enhance the tracking and management of urgent suspected cancer referrals. The initiative has helped improve internal processes that support faster treatment for patients with suspected cancer.

The practice took part in quality improvement work to improve outcomes for patients. The practice carried out regular clinical audits, for example, in prescribing practices, fit testing (a bowel cancer screening home test kit), and long-term conditions. A 6-month audit was conducted on the evaluation of do not attempt cardiopulmonary resuscitation (DNACPR) documentation and review process. This resulted in measurable improvements in the quality and consistency of DNACPR documentation ensuring patient preferences and clinical decisions were accurately recorded and reviewed in line with national guidance for best practice.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff described how they engaged with patients to explain care options and obtain consent in a way that was clear and appropriate to individual needs. Patients did not raise any concerns about how the service sought consent for care and treatment.

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. They supported patients to make informed choices and, where appropriate, assessed and recorded mental capacity in line with the Mental Capacity Act 2005.Staff had received appropriate training in the Mental Capacity Act, and the service monitored the consent process effectively. Patient record audits confirmed that consent was consistently and appropriately documented. We reviewed Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions for 3 patients and found these were made in line with relevant legislation and were appropriate to individual circumstances.