Ledbury Health Partnership

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. This is the first inspection for this service since the two practices merged. This key question has been rated as good.

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.

88% of patients that completed the National GP Patient Survey data agreed that they felt their needs were met during their last GP appointment and 85%felt the healthcare professional they saw had all the information they needed about them during their last GP appointment. Both scores were lower than the local and national average. However, we saw evidence that the practice made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. There were systems and processes in place to identify patient’s needs and preferences. Patients were coded to highlight any specific needs such as requirement for a longer appointment or the need for a translator. The practice met the accessible information standard. A hearing loop was present, interpretation services were available, and the practice adhered to patients’ communication preferences. Staff could refer patients with social needs, such as those experiencing social isolation or housing difficulties to a social prescriber within the primary care network. The patient participation group (PPG) regularly visited the practice to speak with patients to ensure the practice addressed individual needs.

The practice planned and delivered people’s care and treatment with them, including what was important and mattered to them. Meetings were held to ensure staff were updated with the latest information, guidance and changes within the practice.

The clinical searches we undertook of the practice’s clinical records system showed the monitoring of people with long-term conditions was not always followed in line with National Institute for Health and Care Excellence (NICE) recommendations. For example, one of our clinical record searches reviewed the number of patients with asthma who had been prescribed two or more courses of rescue steroids in the last 12 months. We identified a total of 38 patients and reviewed a random sample of 5 patient records. We found that not all patients had been reviewed in a timely manner after an exacerbation to check their response to the treatment. Following this feedback, leaders provided evidence that they had updated their protocol to include prompts on the screen to ensure an appointment is booked within the set timeframe and the practice have created dedicated timeslots in the diary to ensure the appointments can be made to follow clinical guidelines.

We reviewed monitoring of people with hypothyroidism (when the thyroid gland does not produce enough thyroid hormone that can lead to tiredness and weight gain).A total of 751 patients were identified, of these 8 patients were potentially overdue thyroid monitoring. We reviewed 5 patients at random and found that 3 patients were overdue their thyroid monitoring. The practice acknowledged this feedback and provided evidence that these patients had blood test appointments arranged.

We reviewed patients with chronic kidney disease (CKD) stages 4 or 5. A total of 65 patients were identified, and all patients had the appropriate U+E blood test monitoring in the last 9 months. We reviewed the monitoring of diabetes care and found that all patients were receiving the appropriate care, in line with legislation and current evidence-based good practice. The practice shared evidence of clinical audits to improve patient care. We discussed our findings with the practice, and they took immediate action to address the gaps identified.

The practice worked well across teams and services to support patients. They developed a staff charter that outlined the team’s purpose, this included compassion, accountability, respect, inclusion, education and prevention and safety standards. Information was shared between teams and services to enable continuity of care and ensure patients only had to tell their story once when moving between different services. The practice regularly held multidisciplinary team meetings to ensure all teams were up to date with relevant information. Alongside meetings, the practice had ‘lunch and learn’ sessions that often had guest speakers attend to share learning. There was open communication with practices within the primary care network. Staff were supportive of each other to ensure they had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. To ensure staff were able to work together effectively, the practice adopted an open-door policy to encourage staff to speak up so that any queries were resolved to reflect a positive working environment.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. They supported patients to live healthier lives and where possible reduce their future needs for care and support by sharing advice and guidance. 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. Staff members were able to advise and refer patients to the social prescriber that could offer support to improve or maintain their care. Health promotion material was observed in the practice and further information could be found on their website that supported national priorities and initiatives to improve population health by supporting people. A walking group was established by a staff member for patients and staff to join. This offered an opportunity to combat loneliness, improving mental health and physical activity. Patient feedback reflects the positive outcome of this group as patients said the walks were something to look forward too and helped meet other people. A diabetes group clinic was also created to increase patient knowledge and provide a connection with others in similar circumstances. Ledbury Health Partnership was awarded a certificate of achievement by the Royal College of General Practitioners in recognition for achieving an active practice status by reducing sedentary behaviour in both staff and patients and being part of an active community.

Findings from the clinical search records indicated that the practice routinely monitored people’s care and treatment to improve and ensure that both clinical and patient expectations were met. At the time of our assessment, the latest published information from the UK Health Security Agency (UKHSA) showed that the practice did not meet the World Health Organisation target of95% as the observed percentage was 90.9% for the number of children immunised against various infectious childhood diseases. The latest published information from NHS Digital showed the practice’s uptake for cervical cancer screening for women aged 25 to 49 years old was below the 80% national target and was observed at 66.7%. The practice’s uptake for cervical cancer screening for women aged 50 to 64 years old was also below the 80% national target and was observed as 71.9%. Staff told us they were actively engaging with patients to increase these figures. For example, daily notifications were received regarding who was due their immunisations or cervical cancer screening. The social prescriber contacted all non-responders to cervical cancer screening invitations who were not classified as ‘British White’ population group. They also attended a local Afghani ladies’ group to speak to patients via a translator about making an appointment. A face to face translator was offered during these appointments to offer a more personal approach. This had a successful outcome as patients booked a cervical cancer screening appointment following this visit. Staff regularly checked this data and contacted patients accordingly.

The practice told patients about their rights around consent and respected these when delivering care and treatment. Staff understood the importance of consent and respected the importance of obtaining consent before care or treatment was delivered. Considerations regarding consent were also given when providing care to children and young people, and the need to assess the mental capacity of patients to give consent. Patients received information about care and treatment in a way they could understand. Patient’s capacity and ability to consent was considered and clearly recorded. Chaperones were available upon request.