St Peter's Medical Centre

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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 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 in October 2017, we rated this key question as Good. At this assessment, the rating remains the same.

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.

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. For example, during our remote clinical searches, we noted people were being appropriately coded as having diabetes or prediabetes following a review of their blood test results.

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

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. Regular clinical updates were shared with all clinicians during the weekly clinical meetings. Clinical records we saw demonstrated care was provided in line with current guidance.

Clinical audits undertaken by the service led to several quality improvements. For example, an audit of people prescribed testosterone as part of HRT identified gaps in required monitoring. Following action taken by the service, a re-audit showed most people were up to date with monitoring, and appropriate steps were taken for those who did not engage with follow-up.

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 service worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

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 people’s health, including those in the last 12 months of their lives, people 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 worked in partnership with external organisations to support people with additional needs. For example, they hosted a monthly joint clinic with a London-based substance misuse service for people experiencing issues related to drug use, enabling access to specialist support in a familiar setting.

The service also signposted people to a “Conversation Café” held within the church where the service was based. A range of organisations, including housing support, carers’ services, and other charities attended, providing people with access to wider support and promoting their health and wellbeing.

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. However, although the service encouraged people to participate in population screening, they were not meeting national screening targets for cervical screening.

The uptake rate for cervical screening was 68% among eligible women aged 50–64 years and 60% among eligible women aged 25–49 years, compared with the national target of 80%. The service had identified lower uptake for cervical screening and taken steps to improve this. Although they met Quality and Outcomes Framework (QOF) targets (QOF is an NHS system that measures how well GP services provide care and meet key health targets), the service explored barriers by surveying people and found some accessed private care or were commuters, affecting attendance. They promoted screening through a dedicated “smear week,” awareness campaigns, self-booking links and receptionist engagement. Saturday appointments were also offered during the campaign to improve access particularly to commuters. In addition, they explored self-swabbing options and signposted people to local sexual health services for support with this. While we observed initiatives intended to increase uptake, their impact was not yet reflected in nationally reported data.

The provider was achieving 90-95% childhood immunisation coverage for 4 out of the 5 routine childhood vaccinations. Coverage was 85% for children aged 5 who had received 2 doses of the immunisation for measles, mumps and rubella (MMR). There was a clear policy in place for staff to follow to support childhood immunisations. This included managing the immunisation schedule for pre-school children, ensuring contact details for children and their parents were accurate, having a recall system to invite people when vaccinations were due, action plans for children who had missed immunisations, and a process to ensure newly registered children were brought up to date.

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. There was a comprehensive programme of clinical audit and quality improvement activity to review the effectiveness and appropriateness of the care provided. 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.

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, including the Mental Capacity Act 2005. We reviewed a sample of records where DNACPR decisions had been documented. This showed that, where possible, people’s views had been considered and respected, and relevant information was shared with appropriate agencies.