Holbrooks Health Team

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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 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 remains the same.

This service scored 63 (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. Some patients had not received care in line with recommendations and best practice guidance.

As part of the assessment a number of set clinical searches were undertaken by a Care Quality Commission (CQC) GP specialist advisor. A sample of the records of patients with long-term health conditions were checked to ensure the required monitoring was taking place.

Our clinical searches identified 165 patients with raised HbA1c levels (HbA1c shows a patient’s average blood glucose (sugar) levels for the last two to three months). We reviewed a sample of five records and found that, although four patients were under secondary care, overall oversight of monitoring was not effective. A full practice review identified 42 patients who were overdue monitoring (21 under secondary care and 21 under the practice’s care). The practice took action and provided evidence of contacting these patients. However, this highlighted gaps in systems to ensure timely and coordinated follow‑up.

Feedback from people using the service was mainly positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Reception staff demonstrated an awareness of the needs of the local community. They used digital flags within the care records system to highlight individual needs, such as requirements for longer appointments or access to a translator.

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.

However, we found patients’ needs were not always assessed, and care was not always delivered in line with legislation, clinical standards, and recognised pathways and tools. For example, patient records did not always contain sufficient information to support safe prescribing and ensure appropriate care and treatment. Our clinical searches showed that not patients with some long-term conditions such as diabetes and high blood pressure were not effectively followed up.

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. We reviewed the providers referral process and how administrative workflow was managed. We found there were effective systems in place, and the use of a digital system to generate letters supported better communication with patients and efficient record keeping.

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 practice had access to social prescribers where they signposted patients to, the practice also had literature in the waiting areas to inform patients of local and national support.

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.

Although there was a system in place to recall patients for long term health condition reviews, processes for reviewing the uptake of patient monitoring needed strengthening. Results from our clinical searches showed there were some shortfalls in ensuring relevant blood tests had been carried out prior to a review or prescriptions being issued.

The practice was slightly below national targets for screening and immunisations. From the clinical records we reviewed, we found patients receiving care from the service did not always achieve expected outcomes in line with legislation, standards and evidence-based clinical guidance, indicating gaps in the delivery of preventative care.

The provider submitted clinical audits which they had carried out to improve outcomes for patients. Findings from audits were shared with staff to help identify further areas for improvement in outcomes for patients.

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.