Burn Brae Medical Group

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 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.

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.

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. There was a programme of clinical audit in place, and we saw a number of full 2 cycle audits to support quality improvement, such as an audit into the early identification of bladder cancer.

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. For example, we reviewed the clinical records of 70 of the 1441 patients with asthma and 63 of the 678 diabetic patients at the practice, and in each case all reviews were up-to-date and the relevant guidance had been followed.

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.

Feedback from staff at the local care home was highly positive about the way in which the practice worked with them to support patients. Clinicians at the practice also held lead roles across the locality, such as local diabetes lead, which helped to foster good links with other services in the area.

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 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 a strong focus on empowering people to maximise their opportunity to manage their own health, care and wellbeing needs as much as possible, as well as is exceptional collaboration across staff, services and organisations to enable people (with their family and carers) to manage their health and wellbeing at home effectively and where possible, reduce their future needs for care and support. They had trained staff to carry out insulin initiation to reduce the need for newly-identified type-1 diabetic patients to need to be referred to secondary care. Between 7 to 10 patients each year were started on insulin in this way, and in the last 3 years all but 1 of the practice's type-1 diabetic patients had their insulin initiated at the practice. They also invested in staff who were able to help diabetic patients on insulin to use continuous monitoring devices, which allowed them to better manage their conditions. Patients were educated in the use of the devices, and adjustments were made where needed to ensure everyone could use them. In total, 63 patients had been issued with continuous monitoring devices and all had lowered their average blood sugar levels as a result. By providing continuous glucose monitoring devices, the practice empowered patients to understand and manage their blood sugar levels more effectively, helping them take control of their condition and avoid complications. We saw examples of several patients who had used the devices to discover they were experiencing hypoglycaemic episodes, and the diabetic nurse at the practice was able to adjust their insulin use accordingly. The practice had also started prescribing GLP-1 receptor agonists (a type of medicine that helps lower blood sugar and can support weight management in people with type 2 diabetes) for diabetes management and had been able to reduce the number of patients who required insulin as a result. The practice had 678 patients (approximately 7% of the total patient population) on their list.

The service monitored all people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

We conducted searches of the clinical records in relation to various long-term conditions which required ongoing monitoring, such as asthma and diabetes, for example. These searches identified 1,441 patients with asthma and 678 with diabetes. We reviewed the clinical records of 70 of the patients with asthma and 63 diabetic patients, and this showed that reviews were up-to-date, the relevant guidance had been followed, and there were no concerns with how patients were being monitored.

The practice met national targets for screening and immunisations, and had achieved 100% of the points available in the Quality and Outcomes Framework (QoF) in 2024. 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 always carefully explained to people what their rights around consent were, made sure they fully understood them and always fully 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.