South Norwood Hill 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 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 Requires Improvement. At this assessment, the rating has changed to Good.

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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing, and communication needs with them.

At the previous inspection, the systems for identifying and assessing needs required improvement. At this assessment, the practice had made significant improvements in this area. The management of assessing and reviewing patients’ health was robust and comprehensive. There were no findings of concern flagged by the clinical searches with regards to chronic kidney disease and hypothyroidism.

The practice had good systems in place to identify patients at risk of developing long-term conditions. For example, they had two local pharmacies where they referred patients to for smoking cessation. They also coded patients who had blood test results in the pre-diabetes range so that they could be monitored and followed up. Additionally, they provided education and information to these patients regarding diet and exercise to try and reduce the chances of them fully developing or slowing down the development of diabetes.

Reviews for patients with asthma and diabetes were organised through the care co-ordinators and we saw these were carried out in a timely manner. There was a dedicated diabetic clinic which helped the practice maintain good oversight of patients with diabetes.

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. Patient feedback indicated that they felt staff met their needs. For example, one patient said, “staff always go the extra mile”.

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 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. The practice had systems that were effective at identifying patients at risk of developing long-term conditions, such as pre-diabetes support and diet and health information for the prevention of other conditions. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

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. For example, information noted in patient’s records could be accessed by the community nursing team and the local hospital and vice versa.

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 such as community services, commissioners, and voluntary organisations to ensure continuity of care, including where clinical tasks were delegated to other services. Staff told us that they worked well with others as there was “a genuine effort to improve access and reduce inequalities.”

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. The practice had systems that were effective at identifying patients at risk of developing long-term conditions, such as pre-diabetes support and diet and health information for the prevention of other conditions. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

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.

At the previous inspection, the practice was not meeting all national targets for screening and immunisations. At the time of this assessment, the practice was still below target for cervical cancer and children’s immunisation.

Despite being below some targets, we saw evidence that the practice was proactive with encouraging patients for screening programmes. For example, the care co-ordinators have responsibility for going through record to identify and invite women for cervical screening. The practice had three dedicated appointment slots every day for these cervical screening checks. To make appointments more accessible they provided appointments in extended hours so that appointments can be booked outside of patients working hours and on the weekends. They send three text message invites. They also found that impromptu appointments have been utilised. The GP told us that recently six additional appointments were made by simply by asking women after a general appointment is they wanted a screening test. They also have leaflets and information on their website to increase understanding.

The procedures for children’s immunisations had been strengthened also. Staff used a search tool to identify children that required childhood immunisations. They contacted patients three times via phone, text, or letter. The nurse also had a weekly list of parents they contacted with newborn babies.

We also saw numerous examples of the practice contacting patients and patients declining immunisations and screening opportunities.

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 service told people about their rights around consent and respected these when delivering person-centred care and treatment.

All staff had completed mental capacity and deprivation of liberties training. Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. The GP told us that if there was doubt as to someone’s capacity, this was also recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.