Dr Rachel Ng & partners

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 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. Following the clinical searches, the practice put in place arrangements to proactively follow up patients who repeatedly failed to attend monitoring, to ensure diagnosis at the earliest opportunity.

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.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was mainly provided in line with current guidance. We found although there were arrangements in place to review patients prescribed oral steroids for acute exacerbation of asthma within best practice timescales, there were some instances when this did not happen. The practice told us this was discussed at a clinical meeting on the 4 December to highlight the finding and as a reminder to clinicians that they should follow the practice policy. We found there were some patients who continued to fail to attend reviews and monitoring, and the practice had not taken sufficient action to encourage them to attend. The practice told us prior to the site visit; they had reviewed their approach to incentivising and encouraging these patients to attend to support safe management of their condition.

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. We received wholly positive feedback from healthcare professionals from partner organisations that covered the whole life cycle of patients, such as community nursing, health visiting, midwifery, palliative care, social work and the local care home. They told us the practice take a wholistic and compassionate approach to meeting the needs of patients and take into account the views of fellow healthcare professionals. These professionals also told us patients felt at ease to speak freely to the practice clinicians and felt well supported by the surgery.

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, including stopping smoking and tackling obesity.

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 childhood immunisations. The practice was below target for screening coverage for cervical cancer at 70.1% for women aged 50-64 years who had adequate screening within the last 5.5 years and 69% for women aged 25-49 years who had adequate screening within the last 3.5 years; against a target of 80%. The practice told us they knew they had more work to do to encourage uptake but used a personalised approach to contact and follow up patients. 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.