Towcester Medical Centre

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• 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 assessed all the quality statements from this key question. We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. We found staff involved people in decisions about their care and treatment and provided them with 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 79 (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 made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them. Feedback from people using the practice was predominantly positive. People felt involved in the assessment of their healthcare needs and felt confident that staff also understood their individual and cultural needs. Leaders and staff told us the practice used codes and alerts on the patient’s record to highlight special needs and requirements. 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 practice 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 practice 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. Our clinical record searches found patients were receiving safe management and monitoring for medicines within the advised time frame. Our searches found exceptional results with very few patients overdue their reviews. For instance, all monitoring of people with chronic kidney disease had received their reviews and only one patient with Hypothyroid disease was due their review. Leaders informed us they put in place protocols and processes to effectively manage this. There was evidence that patients who did not respond to invitations for reviews or failed to attend appointments continued to be monitored by the practice. Similarly, patients with diabetes received timely reviews. Our searches looked at diabetic patients with raised HbA1c levels to assess whether they had been reviewed and supported accordingly. All of the records we reviewed demonstrated appropriate care and support had been delivered for these patients.

The practice held registers for patients and provided annual health checks for those with learning disabilities, people with severe mental health conditions and palliative patients.

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.

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 processes in place enabled staff to liaise regularly with community teams such as community nurses, health visitors, and palliative care nurses. Staff told us and we saw evidence of regular multi-disciplinary team meetings that were held with external agencies where vulnerable people were discussed and actions recorded. The practice regularly discussed patients receiving end-of-life care.

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. Staff focused on identifying risks to people’s health, including those who are (or might be) vulnerable such 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 practice provided an Age Well service. The Age Well team was an extended holistic primary care service aimed at supporting the population over the age of 65 years. The core aim was to provide a multidisciplinary team (MDT) assessment led by a GP with a specialist interest in the care of the elderly. The service was initially commissioned to primary care networks (PCNs) by Northamptonshire Integrated Commissioning Board (ICB) as part of their Integrated Care Across Northamptonshire (iCAN) Program to provide GP input into a virtual MDT. The GP lead at the practice had expanded the concept beyond the original contractual requirement; providing a fully home visiting service that proactively targeted frail patients who were not acutely unwell, in an effort to optimise their health and wellbeing. There were focuses such as advanced care planning, improving social satisfaction, falls reduction and Dementia support. The home visiting approach was chosen because of the rural geography of the practice, levels of isolation and higher than local and national average demographics of frail elderly frail patients in the area. Initially delivered at individual practice level, at the time of our assessment, the service had been expanded to cover the entire Brackley and Towcester PCN (a population of 50,000). We saw evidence of the service’s success through positive feedback gathered. In addition, the service was a key factor in reduced hospital admissions locally. The MDT comprised of 4 staff, 2 community support workers, the GP and a service coordinator .

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.

The practice met national targets for screening and immunisations. This included all 5 childhood immunisation programmes and cervical cancer screening. Staff advised the practice had developed its own recall systems for patients eligible for immunisations and screening to encourage uptake. 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 practice told people about their rights around consent and respected these when delivering person-centred care and treatment. People we spoke with and the evidence we reviewed did not raise any concerns around consent. People understood their rights about consent to the care and treatment they were offered. Clinicians understood the requirements of legislation and guidance when considering consent. Clinicians supported people to make decisions ensuring their views and wishes were considered during care planning. Assessments of mental capacity were carried out when needed and were decision specific. Staff told us they were able to adapt or translate information about care and treatment so that people could understand, to support them making informed decisions. All staff we spoke to had completed relevant training and were able to discuss how to gain informed consent for treatment. We reviewed a random sample of staff training records which showed staff had up-to-date training on informed consent, the 2005 Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS). We saw that consent was documented and processes were in place for chaperones to be present if requested.

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms were appropriate, regularly reviewed, and made in line with current legislation and professional standards.