Hillview Family Practice Also known as Dr Montague & 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

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved people who were important to the person and took decisions in people’s best interests where they did not have capacity.

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.

Staff were aware of the needs of the local community. They used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments.

Assessments of people’s physical health, wellbeing and communication needs were in place. Care records were clear and up to date and showed appropriate details of health needs and what support was needed. 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.

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.

The remote clinical searches we undertook included reviewing the monitoring of patients with long-term conditions to assess if National Institute for Health and Care Excellence (NICE) recommendations were followed. People with asthma received good overall management, however, a small number of those prescribed rescue steroids were not followed up consistently within the 7-day timeframe.

Our remote clinical searches reviewed records of 5 people with diabetes. This showed there was inconsistent oversight of long-term conditions management to ensure evidence-based care and treatment was given within appropriate timeframes. However, all records reviewed had appropriate management of symptoms and people received medicine adjustments according to recent test results.

We reviewed 5 care records of people with evidence of Chronic Kidney Disease (CKD) and found 4 were overdue reviews.

The service piloted the use of AI (Artificial Intelligence) supported tools during clinical huddles and consultations to support clinicians. The system aligned with national guidance and supported consistent clinical decision making.

If we are recognising shortfalls, can we justify score of 3?

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.

Staff confirmed effective communication between all areas of the service.

We saw evidence of regular meetings which were used to share any changes across the service. There were also meetings to discuss concerns which had a multidisciplinary approach, such as health visitors and midwives attending safeguarding meetings. The service had strong relationships with other GP services, that made up its Primary Care Network (PCN). Staff and leaders successfully maintained positive partnership arrangements with many local providers and charities.

Staff told us they enjoyed the team-working environment and felt comfortable approaching leadership at the service.

Referrals to other services were audited to ensure that appointments were created for patients in a timely manner, such as, when patients were referred for suspected cancers.

The service 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.

The service reviewed people on specific medicinesthat required regular blood test monitoring. They created a protocol clinicians followed and audited its success. The outcome showed that people on those specific medicines requiring blood tests and monitoring received it in line with guidance.

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 services provided a free At Home Cookery Club for people with type 2 Diabetes. This helped people make informed choices about their food and nutrition while educating them on healthier choices.

The service had a social prescriber who was able to use their links in the community to effectively support people to live more independently. For example, helping people complete documents, applying for financial aid and signposting to charities. A social prescriber is a healthcare professional who helps individuals improve their overall well-being by connecting them to non-medical support and community resources.

We saw the service captured relevant information in a person’s care record. This included people's preferences and choices.

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 service was aware it did not meet national targets for screening and immunisations. They had been proactive in improving these. For example, they had a smear improvement project for people with learning disability and autistic people. This included video walkthroughs, images of the treatment rooms, and videos to introduce the clinical staff. This removed any anxiety for people with a learning disability and autistic people to enable them to visit the service to receive care and treatment. This project indicated a positive uptake of an additional 25 people receiving a smear test.

The service offered late night and weekend clinics for smears to encourage people to attend. They also created care packages for young people and their families to educate them on preventable diseases.

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.

Policies were in place and in line with best practise guidance relating to consent and Mental Capacity Act including details of the best interest decision making process.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded.

Staff understood Gillick competency (Gillick competency refers to the legal ability of a child under 16 to consent to medical treatment without parental consent, provided they have sufficient understanding and intelligence to appreciate the treatment's nature, risks, and alternatives) and there was a process to ensure young adults had control over their own privacy and the amount of parental involvement in managing their care and support.

Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. However,someDNACPR forms received from secondary care services were not consistently reviewed. For example, forms completed by consultants during a hospital stay were not consistently being signed by the hospital consultant to validate the form. This required a follow up by the service to ensure the DNACPR form was relevant. The service understood this was an area of concern and immediate action to review the process was implemented.