Narrowcliff Surgery

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 monitored people’s care and treatment and supported them to live healthier lives. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service always supported people to manage their health and wellbeing to fully 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 focused on identifying risks to people’s health, including people living with frailty, care home residents, carers and people with long-term conditions. The service used recall systems, chronic disease reviews and case finding activities to support early identification and intervention. Staff worked with a range of community and PCN partners to support people’s health and wellbeing, including social prescribing, health coaching, mental health support and frailty services.

Staff we spoke with described how health coaching and social prescribing initiatives had supported people to improve outcomes including through diabetes education and wellbeing walks. The service took part in a community nutrition project and demonstrated how this project combined with coaching had reduced weight and blood sugar levels for some people.

The service worked with PCN partners to support people whose health conditions were affecting their ability to work. Through the Fit Note Innovation Pilot, people could access Work and Health Coaches who provided personalised support, including advice about employment, health and reasonable workplace adjustments. This formed part of the service's wider approach to supporting people's wellbeing and addressing wider factors that could affect their health outcomes.

The service worked with primary care network and community partners to support children and young people, including access to the Well Centre for Adolescent Health, which helped young people access support for their physical health, mental wellbeing and wider social needs.[KD2.1]

The service undertook research aimed at improving and early identification of disease and long-term health outcomes. For example, a study exploring social prescribing and the impact of nature-based interventions[KD3.1] such as gardening. A screening programme that identified previously undiagnosed people with atrial fibrillation[KD4.1] a common heart rhythm condition that can increase the risk of stroke that enabled access to treatment to reduce the risk of stroke. and work to improve attendance for blood monitoring among people with a history of gestational diabetes[RB5.1]. Leaders had also invested in a dedicated research suite to local research capacity.

People could also access additional support and services such as, diabetes support groups, pre-diabetes education, a monthly Pain Café and employment support through the Fit Note Innovation Pilot. Leaders also demonstrated an understanding of barriers to vaccination uptake and had implemented processes to identify and support people who may benefit from additional information and encouragement.
 

The service routinely monitored people’s care and treatment to continuously improve it. They ensured outcomes were positive, consistent and met the expectations of people themselves.
The service used a range of clinical audits, chronic disease recall systems and significant event reviews to monitor the quality of care provided to people. Leaders used performance information to review demand, access and clinical outcomes and had implemented quality improvement work in areas including prescribing, chronic kidney disease, asthma management, access and childhood immunisations. Staff used regular clinical searches and recall systems to identify people who required reviews of long-term conditions or medicines monitoring. For example, the service aligned medication reviews and long-term condition monitoring with people's birth months and completed monthly checks to identify and follow up anyone who had not attended their review.
The service had worked with the local immunisation team to improve the uptake of childhood immunisations improving clinical coding, staff communication and regular review of overdue vaccinations. This had resulted in a measurable increase in update The service met the national target of 90% uptake for primary childhood immunisations. Staff demonstrated an understanding of barriers to vaccine uptake and had implemented processes to identify and engage with people who may benefit from additional information and support. The service also undertook targeted quality improvement work in response to identified risks. For example, staff completed an asthma review project to identify and contact people at risk of poorer outcomes and planned further review cycles to monitor improvement. Leaders told us the service regularly reviewed performance data and used this information to identify opportunities to improve outcomes for people using the service. The service regularly reviewed performance data and continued to monitor areas where uptake remained below the national ambition of 95%.
The service also monitored participation in national screening programmes. Cervical screening uptake was below the national target of 80% for both eligible age groups. To address this, leaders continued to review performance data and promote screening to improve uptake among people using the service. 
 

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.