East Harling & Kenninghall Medical Practice

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

This means we looked for evidence people had the best possible outcomes because their needs were assessed and care and treatment was provided in line with up-to-date best practice.

At our last inspection we rated this key question Good.

At this inspection, the rating has changed to Requires Improvement.

This is because the practices processes were not always effective.

People were not always involved in assessments of their needs. Not all assessments took account of people’s communication, personal and health needs. Care was not always based on latest evidence and good practice.

Staff involved those important to people to take decisions in people’s best interests where they did not have capacity.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Results from the 2023/2024 National GP patient survey regarding assessing need showed that 89% of patients said last time they had a general practice appointment; the healthcare professional was good or very good at treating them with care and concern. This compared with a national average of 84%. The same survey showed that 89% of patients said the healthcare professional was good or very good at listening to them. The national average was 85%.

The survey also showed that 90% of patients said they had confidence and trust in the healthcare professional they saw or spoke to. This was below the national average of 93%. We did receive feedback that reasonable adjustments were not always offered or upheld which meant that they struggled to communicate their needs to the practice.

The practice told us that they supported patients and took into consideration any adjustments that were required.

Leaders shared responsibility for supporting carers in the practice.

Processes to ensure that support information for carers was kept up to date were not effective. For example, the carers identification form referred to staff no longer working in the service. We saw minimal information for carers support on the practice website. We were not told about any other activity planned for carer support by staff and leaders.

Leaders and staff told us codes and alerts were added to patient records to identify vulnerable patients or risk groups.

The practice planned to introduce an online triage system to allow patients with access requirements an alternative way of requesting care and treatment.

From our clinical searches of long-term conditions, we found that patients were not always given appropriate safety netting advice to deal with risks that may occur.

Our searches identified 41 out of 1124 patients on the asthma register who had been prescribed 2 or more courses of rescue steroids. This is an indication of poor asthma control. We reviewed a sample of records which found that not all of the patients had received a review in 48 hours following the exacerbation in line with NICE guidance. In addition, there was not always an appropriate follow up of the service users’ asthma and medicines to check treatment was working.

Our searches identified 32 patients as having a potential missed diagnosis of Diabetes.

In addition, 135 patients had not had a medication review in the last 18 months. The templates for annual medication reviews were not always being consistently used and therefore documentation was unclear.

The practice did not appear to have a clear process regarding oversight of electronic record searches to ensure safe monitoring of medicines. Staff at the practice told us that these searches were completed by supporting pharmacists from the Primary Care Network (PCN). The PCN pharmacy team told us they are not involved in providing any support to run searches or audits.

Leaders told us that they had recently transferred clinical systems and therefore some of the coding for chronic kidney disease could be incorrect. They told us that they had plans to undertake further support and training to embed the new system.

91% of the people who responded to the GP Patient Survey said during their last appointment they were involved as much as they wanted to be in decisions about their care and treatment. This was in line with local and national averages.

However, some patients who contacted CQC told us they felt they were unable to get the advice and support required to manage their illness. We were told that some patients had experienced delayed referrals and missed care.

Staff described systems and processes in place to recall and review people with long-term conditions according to their requirements. They also told us that ongoing capacity issues in the clinical team meant that these were not always able to be completed. A waiting list system had been introduced to improve compliance.

Staff told us they were able to attend regular monthly meetings. Leaders told us that these were used to share learning and clinical updates. There were notes taken for those unable to attend but some staff told us that they were unable to access these. There was not a record of who had attended so leaders did not have oversight of staff that may have missed key updates.

Leaders told us they had implemented systems and processes to keep clinicians up to date with current evidence-based practice. These were not always effective as during the clinical searches we found that care and treatment was not being provided in line with national guidelines. Patients with long term conditions were overdue for monitoring and there were delays in reviewing and acting on laboratory results. 84 patients who had received more than 2 courses of steroid treatment in the last 12 months had not been issued a steroid treatment card.

We reviewed the management of patients with diabetes with a most recent HbA1c was >75mmol/l. Overall we found management was in line with national guidance for the management/monitoring of diabetes.

We received both positive and negative feedback about how the provider worked with other services including care homes.

Care homes that worked with the service described good communication and effective processes that had been put in place. This reduced the amount of time care home staff were spending contacting the practice allowing them to focus on delivering care.

Patients who contacted CQC told us that they had experienced delays in care when information was not given to other services. They described missed referrals and changes in medication not being acted on.

Staff described systems in place to work with other organisations, for example to follow up patients. This included ensuring vulnerable patients and children were followed up if they failed to attend appointments.

We were told by staff and leaders that some services provided by the PCN had difficulties in accessing rooms due to the restricted capacity of the building. This meant that patients were unable to be seen in person at times.

The practice held regular multidisciplinary team meetings where they met with community health teams. We saw detailed meeting minutes which showed that they had good oversight of patients who were approaching the end of their life.

The integrated care board (ICB) had been working with the practice to address concerns that had been raised by the local system. The practice had made several changes which were being monitored by them.

There was confusion regarding responsibilities between the PCN and the practice in relation to clinical searches and audit carried out by pharmacists. At the time of inspection, the practice was looking into how to strengthen the communication regarding this.

The practice had previously held meetings and shared information between teams and services to ensure continuity of care for example in relation to safeguarding. This had not happened recently due to pressure on services. The practice wanted to resume these and following the inspection we received evidence that this was now in place.

There were clear and extensive policies in line with regulations regarding data protection. We saw that the practice had support from an external company to ensure that this was fully compliant. This allowed them to share information safely with other services.

People who contacted CQC raised concerns that the staffing challenges and difficulty in accessing care resulted in them being unable to proactively manage their health and wellbeing. Delays in accessing routine monitoring and support had led to people experiencing a deterioration in their health. We were told that patients had felt that they had no option but to seek private healthcare.

Following the introduction of the waiting list process for routine monitoring patients we spoke to on-site told us that they had seen an improvement.

There were no specific programs identified by the practice related to health promotion. Leaders told us that staffing pressures impacted on their ability to carry this out. There were posters and leaflets in the practice signposting healthy living and health promotion work.

Staff and leaders told us they signposted patients to social prescribing services that were hosted at the practice. They had recently expanded this service to include access for young people.

Cervical screening and childhood vaccination rates were lower than averages for the area. Staff were aware of this and highlighted the lack of staff as a key factor in this. They hoped that the waiting list initiative, once established, would help them overcome this.

Staff told us that there were alerts on clinical records to show who were vulnerable and required ongoing monitoring.

Information was available on notice boards within the practice, including about local community groups, services and support groups. This included bereavement support, support with mental health and living with a long-term condition.

The practice had processes in place to support patients with their health and wellbeing. There were alerts on clinical records to show who were vulnerable and required ongoing monitoring.

The practice had offered all patients with a learning disability a yearly health check.

In addition, a large number of patients had been referred to smoking cessation support in the last 12 months.

Out of 2086 patients eligible for an NHS Health check, 466 people had been offered an annual NHS health check. A total of 207 patients had received a completed review. We did not see evidence that the people who had not received a health check had or would be followed up.

Staff told us about their involvement in meetings, including clinical meetings, and attending training to ensure they were kept up to date with best practice.

Leaders identified that with the introduction of a new clinical record system they did not have the same level of oversight of outcomes. They discussed that further training and support would be required.

There was audit activity taking place in the practice. This was used to identify training needs and areas for clinical improvement. Regular audit was not fully embedded, and we saw no second cycle audit activity.

The practice had carried out a review of high-risk drug monitoring in August 2023, following a change in their clinical systems. This involved ensuring all patients needing high risk drug monitoring were up to date. We did not see evidence that this had been updated since.

The practice had carried out audits for monitoring the use of Cefalexin, Ciprofloxacin and Co-amoxiclav between 2022 and 2023. Although they had planned to re-audit in 12 months, we did not see any evidence that this had been carried out.

The provider used the information collected for the Quality and Outcomes Framework (QOF) and performance against national screening programmes to monitor outcomes for patients.

Our clinical searches showed that there was inconsistency in monitoring peoples care and treatment.

The searches highlighted that processes to monitor patient outcomes were not completely effective.

We found examples where urgent abnormal laboratory results were not always dealt with in an acceptable timeframe. The practice did not have a system in place to identify this at the time of inspection and we saw some delays of over a week. This meant that patients were potentially at risk due to the appropriate care and treatment not taking place at the earliest opportunity.

We received mixed feedback about how the provider gained consent from patients. Some patients reported that they had positive experiences of being asked for consent. However, we also heard from patients who told us that there were occasions referrals had been made without their consent first.

Staff completed mandatory training in consent and mental capacity. We saw evidence of monitoring and compliance for staff. Staff we spoke to described the importance of consent.

The practice had consent policies in place.

During the on-site assessment we reviewed the records of several patients who had a Do not attempt cardiopulmonary resuscitation (DNACPR) decision. All of these met the audit standard and showed evidence of high-quality discussion and decision making.
Clinicians understood the requirements of legislation and guidance when considering consent and decision making and we saw that consent was documented.

Staff who performed chaperone duties were trained for the role and had received a disclosure and barring (DBS) check.