Churchfields 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 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 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 practice had systems and processes in place to identify patients’ needs and preferences during the registration process. The practice used digital flags within the care records system to highlight any specific individual needs such as the requirement for longer appointments. Feedback from patients using the service was positive. Patients felt involved in assessments of their needs and felt confident that staff understood their individual and cultural needs. The National GP Patient Survey data found 91% of respondents said their needs were met during their last general practice appointment, which was higher than the national average of 90%.

The remote clinical searches we undertook of the practice’s clinical records system showed the monitoring of people with long-term conditions were not always followed in line with National Institute for Health and Care Excellence (NICE) recommendations. For example, one of our clinical record searches reviewed the number of patients with asthma who had been prescribed two or more courses of rescue steroids in the last 12 months. We identified a total of 60 patients and reviewed a random sample of 5 patient records. We found that not all patients had been reviewed in a timely manner after an exacerbation to check their initial response to the treatment. Prior to us completing the searches, the practice had identified this and had already sent out a communication to staff informing them of the process to follow.Leaders assured us that there was a process now in place to review patients within 48 hours of an exacerbation in line with clinical guidelines.

The practice 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. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. They held regular multi-disciplinary team meetings which included community staff such as district nurses and palliative care nurses.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. The practice supported people to live healthier lives and where possible, reduce their future needs for care and support. Health promotion material was observed in the practice and further information could be found on their website. For example, the practice advertised health advice on their website and had a video containing information on blood pressure. The Patient Participation Group (PPG) supported the practice by providing suggestions on how the practice could continue to improve patient self-care and reduce health inequalities. They supported the practice to run health education sessions covering long term conditions such as diabetes and hypertension (high blood pressure).

The practice 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. At the time of our assessment, the latest information from the UK Health Security Agency (UKHSA) showed that the practice met the national target for the number of children immunised against various infectious childhood diseases. However, the latest information from NHS Digital showed the practice’s uptake of cervical cancer screening was below the 80% national target and was observed as 73% for women 25-49 and 76.9% for women 50-64. The practice recognised this and had made adjustments to improve cervical screening uptake. For example, they ran sessions on a Saturday to target those with weekday access barriers. This led to a better uptake among younger women and those with irregular work schedules. They also ran a targeted non-responder programme for bowel cancer screening. They contacted patients who had not completed their bowel cancer screening test. They did this through a variety of methods such as personalised text messages, follow up calls from trained staff and support with understanding test instructions.

The practice carried out regular clinical audits to help them identify gaps in care and implement improvements. We saw evidence of regular second cycle audits that demonstrated quality improvement and measurable improvements in aspects such as referral processes. For example, one audit looked at the effectiveness of interventions to improving referrals rates to the NHS diabetes prevention programme for patients diagnosed with non-diabetic hyperglycaemia (NDH). NDH is when blood sugar is raised beyond the normal range but is not so high that they have type 2 diabetes. The first audit showed of the 35 patients coded with NDH, only 7 had been offered a referral and 3 were formally referred to the programme. As a result, they implemented several interventions including sending a text template to provide patient education about NDH, requested consent for the referral and added the correct code to patient records. Following the interventions, they completed a re-audit which found 34 out of 39 had been offered a referral and all patients had been correctly coded.

Another audit they completed looked at how effective the practice was at meeting the requirements for prostate specific antigen (PSA) for patients discharged from secondary care requiring ongoing monitoring. The initial audit found 62 out of 71 patients had a PSA blood test in line with the recommended frequency of testing. Following this, they implemented several interventions including using a dedicated code on patients records and worked alongside a recall system to ensure a robust and transparent recall process. As a result, the follow up audit demonstrated measurable improvements to the number of patients who received a PSA test in a timely manner from 87% to 93%.

The practice 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. Chaperones were available upon request and chaperone posters were on display in the practice. Staff who provided this service had completed chaperone training.