Ribblesdale 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

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.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.

Care was based on latest evidence and good practice; however, we found some gaps in how well the practice responded to results that indicated people were pre-diabetic. Immediate and effective steps were taken to resolve this issue. Changes included ensuring quick and appropriate response to all such results and an increase periodical monitoring of this task.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Ribblesdale Medical Practice 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.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

Ribblesdale Medical Practice had systems to identify people with previously undiagnosed conditions, however these needed to be strengthened. As part of the clinical searches, we looked at whether patients with blood-test results indicating they were ‘pre-diabetic’ had completed additional blood tests and been given appropriate advice at an early stage. The clinical search found 27 patients appeared to have missed required additional screening and advice relating to pre or actual diabetes. The list was made available to and discussed with the provider, who investigated the findings and took appropriate remedial action immediately. The provider found that in the main people had not been coded in the electronic system, but they had received timely follow-up checks or care and treatment required.

It was also found, however, that some patients had not been followed up correctly and action was taken make sure they were contacted and offered the correct treatment and advice. This is a significant risk. The provider sent an action plan detailing the action taken to ensure these patients were updated about their health needs and a plan to reduce the risk of a repeat of this omission.

Ribblesdale Medical Practice 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.

Ribblesdale Medical Practice 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 such as GP extended hours.

There were some gaps in reconciling clinical notes between the practices record systems and action was also needed to tighten up how information about medicines is shared when this was managed from secondary care such as a hospital. However robust processes were in place to share information about patients between services, including a local residential home and when people were discharged from hospital.

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 such training staff and for example championing initiatives to improve men’s health through full participation and forward planning to promote health promotion events and special months such as increasing prostate screening for over 45-year-old men during ‘Movember’. The practice also provides an outreach clinic to people who use a local homeless shelter to support people to improve their health and lifestyle and has effectively introduced the role of a Menopause Champion.

All staff at Ribblesdale Medical Practice were trained and able to, after gaining consent, refer patients to the local social prescribing scheme for advice about housing, finances, physical or social activities and other non-clinical advice.

Ribblesdale Medical Practice routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were as positive as possible and consistent, and that they met both clinical expectations and the expectations of people themselves.

People told us they were called in for health monitoring and stated the information provided was helpful and easy to understand.

The practice met national targets for screening and immunisations, and did especially well in meeting the childhood immunisation targets by holding special clinics and working closely with health visitors and school nurses.

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.

Patients using Ribblesdale Medical Practice were told about their rights around consent and this was respected when delivering person-centred care and treatment. People gave examples of doctors and nurses gaining consent. Carers described that doctors were careful to gain consent from the person who had been accompanied and not themselves during consultations.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Records reviewed indicated consent was gained for treatment and care for people who visited the practice.

Staff had completed specialist training about consent and mental capacity as related to adults and children.

Discussion with staff and feedback from patients confirmed information was given to help people to make an informed decision about their care including making plans about what treatment was wanted at the end of their life.

Records confirmed do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.

The service provides care and treatment at a private hospital specialising in care and treatment for children and young adults with complex mental health needs. The provider discussed ongoing work with the hospital in developing care passports to improve information about care needs, including how to legally respond to parental involvement for these patients.