Haden Vale 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

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 has changed to Requires Improvement.

We found that the management of patients with long term conditions needed improving, however evidence provided following the onsite assessment demonstrated that people with long term conditions were offered at least 3 appointments to attend the practice for a clinical review and monitoring of their health conditions.

Patients received care and treatment that supported them to live healthier lives including being supported to undertake national screening programmes and vaccinations. The majority of patients who required monitoring underwent regular checks on their health.

Multi-disciplinary meetings were held where the needs of patients with complex conditions or those approaching the end of life could be discussed, reviewed and planned for.

This service scored 62 (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 did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

During the remote clinical review, we found patients with long term conditions were not always being assessed appropriately. We carried out a clinical search to identify people who had been diagnosed with asthma who had been prescribed 2 or more courses of steroids in the past 12 months. The search identified 25 people. We reviewed a random sample of 4 records and found 1 patient had no details of an adequate assessment having been completed. We found the majority of the asthma reviews were comprehensive, however we identified that the number of exacerbations was not always being recorded appropriately and staff without a prescribing qualification were completing medication reviews. Following the assessment, we were assured that the clinical pharmacists would complete medication reviews. Further review of the records showed none of the patients had been issued a steroid card. A steroid card provides information on how to minimise the risks when taking steroids.

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. Reception 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.

Systems were in place to identify individuals with caring responsibilities, who were offered an annual review. All patients with a learning disability were invited to attend an annual health assessment.

There were appropriate referral pathways to make sure that patients’ needs were addressed. We spoke with staff who were able to describe the process for coding of correspondence and care and treatment records for people. We found that staff had the appropriate skills and training to carry out reviews where appropriate.

The service planned and deliver people’s care and treatment with them, including what was important and mattered to them.

We carried out a remote clinical review to identify the number of patients with diabetes that had a HbA1c over 75 recorded from the latest blood tests. A HbA1c blood test shows the average level of blood glucose. The search identified 77 people. We reviewed a random sample of 3 records and found the 3 patients had overdue medicine and diabetic reviews. Medicine alerts on the clinical records we highlighted reviews were required, however we found these had not been actioned. Following the onsite assessment we received evidence to demonstrate that people with long term conditions were called at least 3 times to attend appointments for a review. When they attended they were seen by a prescribing clinician to ensure they were receiving the appropriate treatment.

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.

We found systems were in place to share information about patients electronically with other services and the provider had a structured approach to meetings ensuring information was shared with the appropriate teams to maintain the care of patients in the community.

Staff told us that they had access to the information they need to appropriately assess, plan and deliver people’s care, treatment and support and they had enough information to plan and refer people and receive subsequent results and information following referral.

There were systems and processes in place to enable information to be shared between the provider and services to ensure continuity of care. The PCN helped to support the practice by providing links to pharmacists, dieticians, mental health practitioners and social prescribers. People were able to receive co-ordinated care between the practice and the primary care network.

The service did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. The service did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

We were unable to gain assurances that there was an effective system in place for monitoring staff carrying out health assessments and the appropriate reviews and advice had been provided. There were alerts on clinical records to show who were vulnerable and required ongoing monitoring, however the recall system needed strengthening to ensure all people with complex health needs and long-term conditions were regularly reviewed and received support to manage their health needs.

We found people with caring responsibilities were offered regular health checks and there was regular engagement with community services and referral pathways in place. The practice website detailed information and links for health promotion, health conditions and common health questions. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. The practice website detailed information and links for health promotion, health conditions and common health questions.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

We found inconsistent approaches to monitoring peoples care and treatment. Some patients hadn’t received an annual review and were not being appropriately monitored to ensure their high-risk medicines and long-term conditions were regularly reviewed. Following the onsite assessment, we received evidence to demonstrate that patients on high risk medicines had been reviewed and monitoring was now in place to ensure they received effective care and treatment and people with long term conditions were sent at least 3 invites to encourage them to attend for their reviews and monitoring of their medicines. However, we continued to identify concerns in the lack of supervision of staff carrying out clinical roles.

The provider was performing in line with the national average for cervical screening targets. The practice had achieved 4 out of the 5 targets for childhood immunisations. The practice continued to strengthen systems and had processes in place to recall patients and implement flagging procedures aimed at promoting opportunistic uptake.

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.