Brigstock Medical Centre Also known as Brigstock and South Norwood Partnership

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
• 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 remains the same.

This service scored 70 (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. Our review of clinical records for patients with long term conditions such as asthma, chronic kidney disease and hypothyroid demonstrated that these conditions were being monitored well. Our review of patients with diabetes identified that in some areas there could have been more follow up and documentation of action taken. For example, some patients had recent blood results that were abnormal. We saw that patients were contacted but when they did not respond there was inconsistencies in follow up. The practice explained that they had followed up on some of them, but it had not been recorded. We were therefore not assured through our clinical record review that this had happened. The practice told us that they would ensure all future follow-up was recorded appropriately.

Feedback from people using the service was generally 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 told us they 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. 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. The practice social prescriber had an appointment list of patients, allocated by clinicians. These included patients in need of help with housing and frequent attendees to the practice. We were told they had successful outcomes when they had signposted patients to other services.

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.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance. Staff carried out annual reviews for people with long-term conditions. For example, we discussed annual reviews of patients with asthma with the nurse who was the asthma lead. The nurse had completed the relevant training to be the asthma lead and had systems and processes in place for effective monitoring.

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. This included links with community nurses, podiatry services, tissue viability and the mental health community teams.

Staff described working relationships with other services as “excellent”. They told us that referrals to podiatry services for diabetic patients was usually done in writing, however if there was an “urgent diabetic foot concern” they would ring the service, and they were referred immediately. Similar arrangements were in place for tissue viability services.

They had a weekly multi-disciplinary team meeting with both internal and external partners. These meetings were well attended by colleagues from the community services (including district nurses and mental health staff).

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.

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.