Chelford 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 assessed all quality statements from this key question. At our last assessment, we rated this key question as good. The rating remains good following this assessment.

We found that staff involved people in decisions about their care and treatment and provided them advice and support. Staff worked together and collaboratively with other services to make sure people could access other services easily.

Patients received care and treatment that supported them to live healthier lives including being supported to undertake national screening programmes and vaccinations. Patients who required monitoring underwent regular checks on their health.

Clinical and non-clinical audits were carried out as a means to improve outcomes for patients. The practice was performing in line with other services within the locality and nationally for data linked to outcomes for patients.

Our review of the clinical patient record system for the sample of patients whose records we looked at showed that care and treatment had been delivered in line with evidence based guidance.

Multi-disciplinary meetings were held on a regular basis where the needs of patients with complex conditions or those approaching the end of life could be discussed, reviewed and planned for. The supporting documents and alerts where people had undergone an assessment for ‘Do not attempt cardiopulmonary resuscitation’ were available on the patient record system.

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.

All requests for appointments were triaged by the duty doctor who prioritised patients who reported symptoms that could be considered a clinical emergency. Patients were told when they needed to seek further help and what to do if their condition deteriorated. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

Staff shared relevant information with other professionals when planning care and treatment. Patients’ treatment records and prescriptions were updated to reflect any changes needed. People living with a long-term condition and those with a learning disability were invited for regular review of their health, care and treatment and staff used templates for this so as to ensure the reviews were appropriately detailed. The provider had effective systems to identify people with potentially undiagnosed conditions, for example diabetes.

Systems were in place to ensure staff were up to date with national guidance, evidence-based good practice and required standards. Staff attended regular meetings, training, educational sessions and underwent regular appraisal.

The experience of people who used the service as indicated in the National GP Patient survey showed that 96% of respondents (compared to 92% nationally) stated that during their last appointment they had confidence and trust in the healthcare professional they saw or spoke to.

We looked at the workflow for managing clinical correspondence and tasks and found these were up to date. Our review of the clinical record system for the sample of people whose care and treatment we looked at, indicated that people received care, treatment and support that was evidence-based and in line with good practice standards. The results of the clinical searches for the management of patients living with long term conditions were good and did not identify any significant gaps in the monitoring of patients.

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 and shared records and information where relevant

Leaders and staff worked closely with colleagues in the local primary care network (PCN) to meet the needs of the patient population.

Multi-disciplinary meetings were held on a regular basis so that when people received care from a range of different staff, teams or services, this was co-ordinated.

People who were the most clinically vulnerable were prioritised and the practice worked with other healthcare professionals to deliver coordinated packages of care.

The service supported people to live healthier lives and manage their health and wellbeing. 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 local and national priorities and initiatives to improve population health, including smoking cessation, encouraging patients to take up national screening programmes and patient education events which were also supported by the Patient Participation Group (PPG).

People living with long term health conditions underwent regular monitoring. They were referred or signposted to local support services for information, education, advice and support linked to their needs. This included referral for diabetes education, dietary advice and smoking cessation. Patients were encouraged to attend cancer screening and to take up childhood vaccinations offered as part of national programmes and the World Health Organisation targets had been met and exceeded in these areas. The practice contacted patients who did not attend to encourage uptake of these services.

The Patient Participation Group (PPG) worked alongside the practice to promote projects or organise events such as ‘keeping safe in winter’ and breast cancer awareness.

Members of the clinical team provided patients with information and support to manage their own health, care and wellbeing where possible. People were also encouraged and supported to make healthier choices to help promote and maintain their health and wellbeing and prevent deterioration.

Our review of the clinical record system indicated that patients received care and treatment that supported them to live healthier lives.

The service routinely monitored people’s care and treatment to continuously improve it. People who required monitoring underwent regular checks on their health.

From the clinical records we reviewed, we found that people who used the service experienced positive outcomes in line with best practice guidance. Leaders demonstrated that monitoring and improving outcomes for patients was important to them and they used information and data to drive improvement.

Clinical and non-clinical audits were carried out as a means to improve outcomes for patients. The practice was in line with other services within the locality and nationally for outcomes for patients.

People who used the service felt they could make an informed decision about their care and treatment because they had been provided with the information they needed to support them to do so. The National GP patient survey results showed that 96% of respondents (compared to 91% nationally) stated that during their last appointment they were involved as much as they wanted to be in decisions about their care and treatment.

Staff understood the importance of ensuring that people knew what they were consenting to and the importance of obtaining consent before they delivered care or treatment. Staff had undergone training in the Mental Capacity Act. Staff understood the requirements of legislation and guidance when considering consent and decision making. We looked at a sample of ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions in patient records. Appropriately completed documents were available and had been shared with other relevant services and alerts had been added to the patient record system.