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

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 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.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. The practice had identified 80 housebound people with long-term conditions had not received regular reviews. In response to this, the practice nurses had commenced home visits to complete these. Systems for monitoring people with diabetes, chronic kidney disease and hypothyroidism were mostly effective.

However, systems to identify people with previously undiagnosed conditions such as chronic kidney disease were not effective because coding had not always been correctly added to people’s records to ensure they did not miss out on essential monitoring.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this mostly in line with legislation and current evidence-based good practice and standards.

Systems were mostly 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. However, follow up of people with asthma prescribed rescue steroids following an exacerbation of their asthma was not in line with national guidelines.

The service worked well across teams and services to support people. They worked with the wider multi-disciplinary team to support people near the end of their life. They worked closely with the Primary Care Network to address the wider determinants of health such as loneliness and isolation. For example, the care-coordinator had organised events in village halls to invite carers to attend with the person they cared for and offered activities such as exercises and massages. They also sent out information about local groups and referred carers to the social prescriber if they needed additional support. 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.

Staff were extremely positive about how the different staff groups worked together within the practice and told us there was a supportive culture across the whole team.

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 and those with caring responsibilities. Carer’s packs were available within the practice and carers were also offered annual carer reviews. The service referred carers to the care co-ordinator and social prescriber, with their consent, if they needed social support or aids within the home. People at risk of diabetes were offered lifestyle advice and referred to the diabetic prevention course. 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.

The practice met national targets for childhood immunisations. For example, all 5 childhood immunisation indicators met the required 90% target and 4 met the WHO based target of 95%. The service had achieved the 80% uptake rate for cervical screening for women aged 50 to 64 and, at 77%, was slightly below the target for women aged 25 to 49 years old. There were systems in place to recall women who failed to attend for their screening, and the practice nurses offered opportunistic screening if there was an alert on the patients’ record to highlight the screening was required.

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.

Staff understood and applied legislation relating to consent including people that lacked mental capacity and children and young adults. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.