The Limes 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 patients were received effective care and treatment.

We found the practice supported people to live healthier lives and there was effective teamworking between staff and services. There was monitoring and improvement of outcomes; however, patients’ needs were not always assessed and regularly reviewed.

This service scored 67 (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 provided effective care and treatment in some areas; however, gaps in supporting systems and processes meant standards were not applied consistently.

We found there were systems in place to assess patients’ needs using the appropriate clinical tools, such as the tools to identify patients living with frailty and at risk of falls. The practice had 4 clinicians with a special interest in dermatology and they were able to offer dermatoscope assessments for patients with skin lesions.

The practice had a recall system in place to undertake long-term condition reviews. Patients on their dementia and mental health register were offered an annual health review. Clinical staff used templates when conducting care reviews and people’s health, care and wellbeing needs were checked during health reviews and after hospital admissions. They also had systems to identify people with previously undiagnosed conditions; for example, patients with potential missed diagnosis of chronic kidney disease (CKD).

However, we also found some gaps in managing risk to patients. When we looked at potential missed diagnosis of chronic kidney disease (CKD) stage 3-5, we found 10 patients were identified as having potential missed diagnosis. We reviewed a sample of 5 of the 10 records and found 3 of these patients had a confirmed diagnosis but had not been informed of the diagnosis and only 2 had been prescribed the appropriate medicine. We discussed our findings with the practice who told us these 3 patients had only had a blood test the week prior, following their monthly searches and they also provided assurances that these patients had been informed of their diagnoses.

Feedback from people using the service was mixed with regards to assessing their needs. Feedback sent directly to CQC from 20 patients showed the majority felt involved in the assessment of their needs and felt confident that staff understood their individual and cultural needs. For example, some of the patients with complex health needs were satisfied with their care; however, at least 3 patients felt their needs were not understood when experiencing acute symptoms, so they had to seek a second opinion and treatment privately.

Feedback also sent directly to the practice praised clinicians for a positive experience when being assessed for new symptoms; however, some patients did not feel their needs were assessed effectively; for example, in relation to assessing new symptoms.

We also found some gaps in assessing needs. When we carried out our clinical record searches, we found 73 out of 2,074 patients on the asthma register had been prescribed 2 or more rescue steroids in the past year due to an exacerbation of their condition. When we reviewed 5 of the 73 records, we found that although all 5 of these patients had received an adequate assessment at the time of prescribing rescue steroids; however, 4 of these patients had not been followed up to check response to treatment a week after being prescribed rescue steroids and this would place them at risk of deterioration. Following the inspection, although the practice implemented an action plan to schedule a follow up at the time of the initial consultation, there was no action taken for the patients we found on inspection that had not been followed up to check response to treatment for their exacerbation.

Systems were mostly in place to ensure staff were up to date with evidence-based guidance and legislation and we saw evidence of nursing staff sharing the latest guidelines with the practice. The practice told us they circulated guidance to all staff groups, which was also discussed at weekly clinical meetings. Managers told us clinician’s phones had the NICE and BNF national guidelines available on them. Clinical meeting minutes were circulated by email; however, 4 of the 5 reviewed did not record attendee names. This meant we could not be assured that staff who were absent received key updates.

Our clinical records searches showed generally patients’ conditions were managed effectively and in line with current guidance. We also found overall low numbers of overdue chronic disease monitoring and several examples of positive outcomes for patients who received evidence based care. For example, one casereview demonstrated effective multi-disciplinary team working and evidence‑based care, with Cytosponge screening in primary care leading to timely referral and minimally invasive resection of pre‑cancerous tissue for a patient, preventing progression to serious disease.

Although we found overall effective care and low numbers of overdue chronic disease monitoring, there were gaps in some areas. For example,we found 20 out of 620 patients diagnosed with hypothyroidism were overdue their monitoring. When we reviewed 5 of the 20 patients, we found 2 of them were overdue monitoring and the practice had not short scripted as per national guidance. There was a risk that these patients would be under or over treated for their hypothyroidism. Following the inspection, the practice provided an action plan whereby they had implemented a short-scripting process for when patients did not comply with their monitoring. The lead GP shared this new system with the clinical staff and we saw evidence of a short scripting message sent out to the 2 patients if they did not attend their blood test monitoring.

We also found that 3 out of 65 patients diagnosed with chronic kidney disease (CKD) stage 4 or 5, had not received recent blood test monitoring in their records. We reviewed all 3 of these patients and found 1 was overdue monitoring and they were at risk of deterioration if not monitored. Following the inspection, we saw evidence of a short scripting message sent out to the 1 patient if they did not attend their blood test monitoring.

We also found 154 out of 1,100 patients diagnosed with diabetes had high HbA1c levels indicating poor diabetes control and when we reviewed 5 of the 154 patients, we found 2 were overdue their diabetic review and although they had been invited for their review they had not complied and 4 were overdue their medicines reviews in the last 12 months. However, 1 of these patients was only overdue by a month. There was a risk that their condition would deteriorate if not reviewed. We did not find any evidence of what further action the practice took to ensure their monitoring was carried out. Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely most of the time.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. They worked with a wide variety of services to ensure continuity of care, including where clinical tasks were delegated to other services. They also worked well across teams and services to support people. They had a wide variety of inhouse staff ranging from their front of house team overseen by a front of house manager to an IT lead who was supported by 2 supervisors to oversee reception and admin staff. The practice also had a duty team comprising an acute GP, duty healthcare assistant (HCA) and duty clinical pharmacist. They had a secretarial team and personal assistants to the GPs and manager and had increased their administration team numbers to enable efficient team working.

The practice also employed 4 Additional Roles Reimbursement Scheme (ARRS) staff, a program that funds Primary Care Networks (PCNs) to hire multidisciplinary teams to support general practice, such as the social prescriber and care co-ordinator. They took an integrated care approach with other organisations such as the referral hub for community services, as well as the local hospice and engaged end-of-life care with 8 of their care homes. They had a strong relationship with their local hospice and their consultants and specialist teams. The practice had a clinical pharmacist who was a Macmillan information pharmacist and dementia friend and 3 members of staff had the International Certificate in palliative care. Their extended care practitioners (ECPs) who were advanced paramedics ensured advanced care planning for patients including the requesting of anticipatory medicines and care education.

The practice provided dedicated medical care to a neurological rehabilitation nursing home for approximately 20 patients with acquired brain injury. A designated GP had oversight of care and attended multidisciplinary team (MDT) meetings for over 10 years. Clinical pharmacists completed medicines reviews for residents. MDT meetings included the GP, nursing staff, occupational therapist, psychologist and a visiting psychiatrist. The lead nurse presented clinical concerns during monthly virtual ward rounds chaired by the designated GP, with a second GP-led meeting held later in the month for additional queries. Patients also received input from neurology and neurosurgical specialists in secondary and tertiary care and the practice escalated to other specialists when required.

We saw evidence of the practice going above and beyond for their extremely unwell patients; for example, one of the GPs would accompany their complex patients to their consultant appointments.

We asked all 8 care homes looked after by the practice how they worked with the practice and they told were mostly complimentary of how they worked together.

The practice provided feedback from the stakeholders and the Primary Care Network (PCN) which showed good collaboration and teamworking. They also participated in the PCN’s workforce wellbeing survey carried out in February 2024 and completed by 44 staff. Results showed that all 44 teams agreed that teams within the organisation worked well together to achieve their objectives.

Complex cases were discussed in the practice inhouse MDT meetings. They had a learning disability team which included a GP lead and HCA, to ensure all patients had annual health checks. They worked with external agencies for those hard to reach and they supported 2 residential learning disability facilities.

The provider told us diabetes care in the practice had improved with closer integration between their non-clinical and clinical planning for recalls and the provision of a named healthcare assistant to coordinate the patient’s journey. They worked closely with the health visitors, school nurses and midwives to identify any families or young people who were vulnerable and in need of extra support.

The practice at the main Epping site was attached to a community pharmacy which shared the same building. The practice worked closely with local pharmacies to offer patients a new referral pathway of their Pharmacy First service, set up to enable the management of 7 conditions across various age ranges. They also offered a more convenient way to access healthcare, including ambulatory blood pressure monitoring.

From August 2020 to August 2022, the provider was the sole practice to support the local hotel when approximately 190 refugees and asylum seekers were moved in for safe housing provision. They worked directly with external government agencies, integrated care systems, local services and the charity sector to provider a tailored service to ensure initial health checks, immunisations and provision of ongoing extensive mental health support. Patients had access to a designated clinician with experience with international medical organisations. They also worked with the translation service to offer different interpreters. In 2023, the practice also worked together with other local practices to care for these residents.

We saw how well staff worked together through their monthly practice newsletters, consistent with our observations on inspection. All the 21 staff feedback forms we received told us there was a strong and excellent sense of teamwork amongst both clinical and non-clinical staff. They enjoyed working within the multidisciplinary teams where everyone’s input was respected and collaboration was key. Staff also felt the wide variety of skill sets in the team enabled them to provide a more integrated approach.

We saw MDT meeting minutes which showed case discussions and relevant updates shared amongst the different team members such as the mental health team, social worker, community matron and end of life nurse. We also saw evidence of clinical, reception and nursing team meetings, as well as Time to Learn sessions. We also saw evidence of meetings with their virtual Patient Participation Group (PPG) which had 600 members.

Staff could refer older people requiring additional support or those with social needs, such as those experiencing social isolation or housing difficulties to a social prescriber.

The practice always supported people to manage their health and wellbeing to fully maximise their independence, choice and control. We saw notable practice in relation to how the practice 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 and patients at risk of developing a long-term condition. For example, a designated team was involved in a case finding project for patients with potential hypertension. NHS Health checks were offered to patients aged 40 to 74 years. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity and this was consistent with patient feedback where they were referred to their dietitian and gym sessions. The practice had inhouse dieticians who could refer patients to the weight management service. All their healthcare assistants were trained in smoking cessation.

The practice also had carers registers which included young carers who were offered health checks. The practice had 296 carers (2% of their practice population) including young carers. They were invited to face to face carers meetings to give them an opportunity to meet and discuss and support each other and were also supported by the practice team including social prescribers. One of the patients we spoke to told us they were on the practice carer’s register and they were happy with the support provided.

The nursing team offered contraception and sexual health advice. The practice website offered patients access to different local services and a variety of links to access patient resources, a variety of wellbeing services and links to the care co-ordination centre self-referral hub for community services.

The patients we spoke to also told us they were regularly called in for health screening.

The practice routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Staff including clinical pharmacists, healthcare assistants and the nursing team were all involved in managing and monitoring long term conditions and patients with learning disabilities. Clinical staff told us they were usually allocated different specific areas in a smaller team every year to focus on; however, they also carried out opportunistic long-term condition and medicines reviews when they saw patients in the practice. The practice had a chronic care management clinic which had been setup by their physician associate.

The practice carried out a significant amount of quality improvement activity such as 2-cycle medicines audits and minor surgery audits. Other quality improvement work included identifying patients on repeat hormone replacement therapy and repeat contraception. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The cancer prevention data for 2023/24 showed that 71% of patients aged between 53-70 years had received breast cancer screening and this was above the national average of 70%. Data also showed 73% of patients between 60 to 74 years of age had received bowel cancer screening and this was above the national average of 72%. The number of new of new cancer cases treated resulting from an urgent suspected cancer referral for 2023/24 was 52%, which was comparable to the national target of 56%.

The practice met national targets for childhood immunisations in 3 of the 4 indicators, with the lowest indicator for children aged 2 years old who had received their measles, mumps and rubella (MMR) immunisations at 89%, just below the 90% target. Patients were offered information which was available in different languages and missed appointments were followed up; however, the practice told us there was vaccine hesitancy in the area particularly since the Covid-19 pandemic.

The practice had policies and procedures for obtaining consent to care and treatment, aligned with current legislation and guidance and a designated lead was in place. The consent and Mental Capacity Act (MCA) policy was reviewed annually. Training records indicated that most staff had completed consent training but records were missing for 5 salaried and sessional GPs. Additionally, 4 clinical and non-clinical staff were overdue for the 3-yearly MCA training. While policies existed, we were not assured that all staff consistently understood and applied consent legislation, particularly regarding Gillick competency, Fraser guidelines and consent when sharing results. Gillick competency and Fraser guidelines are legal and ethical concepts used in the UK to determine whether a child under 16 can consent to their own medical treatment without parental involvement.

Records we reviewed showed capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. On inspection, we found 171 patients were currently on a DNACPR and when we sampled 5 of those patients records, we found the forms had been completed appropriately. We saw positive patient feedback on how the wishes of their deceased loved ones were honoured by the practice.

The extended care practitioners (ECPs) ensured that DNACPR systems and processes were in place and documentation returned to the patient’s home in a timely manner. Staff understood best interest decisions and how they were applied to their care home patients.

Nursing staff described the written consent process with regards to ear irrigation and we saw records of this on their clinical system. We saw evidence of various consent audits such as the vasectomy consent audit and steroid injection consent audits.