Lower Gornal 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.

Systems for assessing individuals’ needs and implementing evidence-based guidelines required further development. People’s needs were not consistently assessed, and care records did not always reflect the care and treatment provided or required.

Staff meetings were infrequent and lacked documentation, limiting visibility of how teams collaborated to support individuals and plan care effectively.

This service scored 58 (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 mostly ensured that people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them; however, this was not always consistent as records did not always provide sufficient detail.

Feedback from people using the service felt that their needs were met and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community and 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. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing; however, during our clinical searches we found that health, care, and wellbeing needs were not always consistently reviewed during appointments. In some cases, individuals had attended appointments but were overdue for essential monitoring, which had not been addressed.

The provider had systems in place that effectively identified people with previously undiagnosed health conditions.

The service planned and delivered patients care and treatment with them, including what was important and mattered to them. However, we identified instances where staff may have operated beyond their defined scope of competency. For example, pathology reports were completed by an advanced nurse practitioner without documented assurance of competence in this area.

Systems to ensure staff remained up to date with national guidance, evidence-based practice, and required standards needed further development. Clinical searches highlighted areas where current guidance had not been consistently followed. While a nursing meeting had been held, there was no structured or consistent mechanism for sharing updates or promoting good practice across the wider clinical team.

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 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 focused 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 provider had systems in place to monitor and improve patient care and treatment. However, outcomes were not always consistent or aligned with both clinical expectations and patient needs. The practice’s uptake rates for cervical screening and one of five childhood immunisations fell below national targets. While a recall system was in place to prompt patients to attend screening appointments, we observed that some individuals with long-term conditions were overdue essential blood tests and had been recalled multiple times without clear follow-up action.

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.

Staff understood the importance of ensuring that people knew what they were consenting to and the importance of obtaining consent before they delivered care or treatment, however not all staff had completed annual training in the Mental Capacity Act (MCA) or learning disability and autism.