Carn to Coast Health Centres

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 assessed all quality statements in the effective key question. Our rating for this key question remains good. We looked for evidence that staff involved people in decisions about their care and treatment and provided them with the necessary advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this. 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 those important to people when making decisions regarding best interests when the person did not have the mental capacity to make their own decisions.

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 assessed people’s care and treatment effectively by reviewing their health, care, wellbeing and communication needs with them. People felt involved in the assessment of their needs and they felt confident staff understood their individual needs. Staff and leaders were aware of the needs of the local community. Reception staff used digital flags within the electronic care records system to highlight any specific individual needs, such as some patients with a learning disability or complex needs requiring a longer appointment. 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 service 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, national standards and recommendations. Systems were followed 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 searches identified 105 patients had received 2 or more courses of rescue steroids in the last 12 months due to an exacerbation of asthma. We viewed 5 of these patient records and found all had been reviewed or monitored appropriately in line with 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 or received from other services. Staff told us they felt well supported and enjoyed working at the service. Staff made positive comments about the supportive team environment. Feedback from partner organisations was also positive, highlighting effective collaboration in supporting vulnerable people. They told us staff were approachable, responsive and attentive to their concerns regarding the individuals they support.

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 to improve population health, including stopping smoking and tackling obesity. The service website contained information and links to other sources of information to support people to make healthier choices and support their lifestyles.

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. Staff followed established processes to ensure people, who were prescribed medicines with specific risks, received recommended monitoring. The practice met national targets for immunisations. The practice met national targets for immunisations. Verified data for cervical screening available at the time of this assessment was from June 2023 and showed the service had achieved an uptake rate of 71.6%, not meeting the national target of 80%. However, unverified data provided to us by the service demonstrated they had achieved the 80% uptake target for the qualifying period between 2024-25. From the clinical notes we reviewed, we found people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. People with long-term conditions were offered an effective annual review to check their health and medicines needs were being met in line with guidance. Our clinical searches identified 1227 people diagnosed with hypothyroidism (a condition where the thyroid does not produce enough hormones). We identified 31 people who had not received the appropriate monitoring in the last 18 months and reviewed 5 of these patient records. We found 2 of these patients had not been invited in for monitoring within this timeframe. When we highlighted this to the practice, they immediately took action and contacted these patients.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. Policies, protocols, and guidance were followed to support people to consent to care and treatment. Staff had completed training and understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions recorded in Treatment Escalation Plans (TEP), were appropriate and were made in line with relevant legislation.