Clement Road 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 remains the same.

This service scored 71 (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.

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. The practice 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. Systems were in place to identify individuals with caring responsibilities. All patients with a learning disability were invited to attend an annual health assessment and long-term condition reviews were carried out to those patients who were housebound.

Staff checked people’s health, care, and wellbeing needs during health reviews and there were appropriate referral pathways to make sure that patients’ needs were addressed. 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. Care plans and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) records were completed and reviewed regularly.

Score: 3

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 and standards.

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.

Our remote clinical searches identified 197 patients with hypothyroidism (a condition where the thyroid does not produce enough hormones) had up to date monitoring. We reviewed 5 records and appropriate monitoring was in place.

Our remote clinical search identified 26 patients with asthma who had been prescribed 2 or more courses of rescue steroids in the last 12 months. We reviewed 5 patients and found appropriate management and an asthma review had been completed.

Our remote clinical search identified the practice had 74 patients with diabetes whose latest HbA1c (blood glucose) level was consistently high. We reviewed 5 patients and found 4 patients had been followed up and 1 patient had been recalled. In those 5 patients, 4 had received an annual diabetic review and 1 patient was overdue a review.

Our clinical searches identified 10 patients with chronic kidney disease (CKD) stages 4 or 5. Of these, only 1 patient was overdue a review and had been recalled at the time of our assessment.

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.

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. Patients were encouraged to take an active role in reviewing their health and were given support to recognise changes in their own health and wellbeing. Health promotion material was observed in the practice. The practice told us this was supplemented by targeted patient communications where appropriate. Further information could be found on their website that supported national priorities and initiatives to improve population health by supporting people.

The service routinely monitored people's care and treatment. However, outcomes were not always in line with national targets across all areas.

The practice was performing in line with national averages for both bowel and breast cancer screening. Cervical screening uptake was below the national target of 80%. The practice achieved a screening uptake rate of 61% for women aged 25 to 49 years and 65% for women aged 50 to 64 years. Childhood immunisation uptake ranged between 89 and 91% across the measured indicators.

Leaders demonstrated an understanding of the factors affecting uptake of preventative healthcare interventions, including language and cultural barriers that can make health promotion and patient engagement more challenging. The practice also recognised that local levels of deprivation may contribute to lower uptake of some services. To help address these challenges, the practice worked with a cancer care coordinator and other practices within the Primary Care Network (PCN) to deliver a community health event focused on improving awareness and uptake of cancer screening.

At the time of our assessment, the practice was also collaborating with other PCN practices on an immunisation campaign aimed at increasing childhood vaccination uptake. The initiative, known as 'Jab Your Bab', aimed to use social media platforms to promote key messages and raise awareness of the importance of childhood immunisations.

The practice had an established programme of clinical and non-clinical audits and action plans aimed at driving continuous improvement in patient care and operational efficiency. For example, the practice had implemented an audit for the monitoring and safety checks for patients prescribed Methylphenidate(this is a medicine used to treat attention deficit hyperactivity disorder. Other audits included Hydroxychloroquine Retinal Monitoring (a medicine used to treat autoimmune conditions).

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.