The Eaglescliffe Medical 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 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 outstanding. At this assessment, the rating has changed to good. At this inspection we found that some of those areas previously regarded as outstanding practice were now embedded throughout the majority of GP practices. While the provider had maintained this good practice, the threshold to achieve an outstanding rating had not been reached. The practice is therefore now rated good for providing effective services.

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. 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 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. We saw positive feedback from people about the social prescribing service.

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.

We saw evidence that clinical updates were discussed in meetings, where presentations were given by area specialists. The practice had protected learning time in which staff could attend educational sessions.

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. Our sample of care records showed that all DNACPR forms had been shared with the appropriate services. We saw evidence of staff working with external healthcare professionals such as district nurses to provide joined up care.

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, to 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.

There was information available on the practice website about self-referral services that were available to patients, such as mental health and pregnancy support. Information was also available within the practice waiting area. Weekly drop-in sessions with a social prescriber were available to all patients. We saw that training on identifying carers had been provided to staff at the practice.

Leaders at the practice were involved in research around the use of social media in public health education and referral pathways. The practice produced social media videos to promote referrals to the NHS Type 2 Diabetes service. From this there was a large increase in the number of patients who used this service. The leaders were scheduled to present this research and promotion at a national conference.

The service routinely monitored people’s care and treatment to continuously improve it. They 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. From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. We saw protocols were in place for long-term condition monitoring, which were followed by staff at the practice.

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. Leaders had conducted a survey with patients who had received minor surgery, in which patients were asked about consent and their understanding of their procedure. The feedback from people in this area was good.