The Streatfield Medical Centre

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 in October 2016, 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 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. All 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.

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 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.

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 aimed at improving population health, such as smoking cessation and tackling obesity. For example, patients were provided with information about local smoking cessation services, and referrals could be made to weight management programmes. The practice also developed targeted text messages to signpost patients to these services.

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.

There was a comprehensive programme of clinical audit and quality improvement activity to review the effectiveness and appropriateness of the care provided. 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.

Whilst the practice team encouraged people to participate in population screening (e.g. the cervical screening programme) and the childhood immunisation programme, the practice was not meeting national screening targets in these areas. The provider was achieving 66-70% childhood immunisation coverage for 4 out of the 5 routine childhood vaccinations. Coverage was 49% for children aged 5 who had received 2 doses of the immunisation for measles, mumps and rubella (MMR).

The service had conducted a thorough review of this area, both internally and in collaboration with external stakeholders. Key challenges identified included vaccine hesitancy and misinformation within specific communities; language and communication barriers; difficulties maintaining contact with families living abroad; and limited awareness of immunisation schedules and their benefits. The service also discussed the issue of low immunisation uptake with the Patient Participation Group and found that misinformation and negative commentary were circulating within the Romanian community.

In response, several targeted initiatives were introduced. These included collaboration with an immunisation coordinator to support community outreach efforts at local children’s centres and community charities. Additional measures involved targeted multilingual SMS campaigns directing individuals to educational resources; the distribution of physical and digital leaflets to support parental understanding and informed decision-making; and the use of promotional videos highlighting the benefits of immunisation. To maintain an effective service, the team continually monitored their recall system, staff training, catch-up clinics, and data reporting processes. While we observed evidence of community engagement and initiatives to increase uptake, their impact was not yet reflected in nationally reported data.

The uptake rate for cervical screening was 77% (national target 80%) for eligible women aged 50 to 64 years old and the practice informed us that this was attributed to a stable, long-standing patient cohort with strong continuity of care and active engagement with the local screening programme. In contrast, uptake among women aged 25-49 was 59%. The practice was aware of this trend and had identified barriers to uptake. These included: population dynamics which showed that younger patients were often from Romanian and Indian migrant communities with high transience; many patients underwent cervical screening in their country of origin which was not recognised by NHS screening programmes; language barriers within specific communities; limited awareness of the purpose of screening; and recent childbirth or multiple pregnancies affecting availability within the screening window.

The practice has taken proactive steps to address these challenges, including personalised recall and patient review; digital and multilingual communication; flexible access and availability of appointments; and staff engagement and systematic follow-up. Practice leaders regularly monitored these processes to drive improvements in uptake and ensure alignment with national performance targets. While we observed evidence of community engagement and initiatives to increase uptake, their impact was not yet reflected in nationally reported data.

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.