Church Lane Surgery

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• 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 with advice and support. The practice ensured that patients were involved in assessments of their needs and staff made sure they understood their care and treatment, to enable them to give informed consent. Staff reviewed assessments taking account of their communication, personal and health needs and involved those important to patients, supporting their best interests where they did not have capacity. However, we highlighted gaps in the management of some patients with long-term-conditions in line with national guidance.

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

Feedback from people using the service was positive. In the recent National GP Patient Survey, 94% of respondents said they felt their needs were met during their last practice appointment (national average 90%).

As part of our assessment, a CQC GP specialist advisor (SpA) conducted a series of remote clinical searches of patient records to assess the practice’s procedures around the management of patients with long-term conditions. For example, asthma, chronic kidney disease, hypothyroidism, diabetes and the potential missed diagnosis of diabetes. We found gaps in the management of some patients with long-term conditions, which included patients with asthma who had been prescribed two or more courses of rescue steroids to treat exacerbations of asthma in the last 12 months, patients with diabetes, whose latest HbA1c was more than 75mmol/l, and the potential missed diagnosis of diabetes. The practice discussed that there had been a recent issue raised by the hospital laboratory regarding falsely elevated HbA1C readings due to a calibration error. The practice had organised patients to have repeat blood tests. The practice was responsive to our feedback and reviewed some patients highlighted from the clinical searches, undertook an audit and provided an action plan. The management of patients with hypothyroidism and chronic kidney disease was generally good.

The practice worked well across teams and services to support patients. Staff told us they had access to the information they needed to appropriately assess, plan, and deliver care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. There were regular documented multi-disciplinary team meetings.

The practice supported patients to manage their health and wellbeing to maximise their independence, choice and control. Staff told us they were committed to promoting and encouraging patients to live heathier lives. They told us they used consultations to opportunistically discuss health choices and provide supporting information. This included encouraging patients to attend health checks and reviews and signposting to support groups and self-help advice. We saw that the practice utilised influenza vaccination events to promote health education and awareness, including social prescribing. Staff told us they supported national health priorities, initiatives and screening programmes to improve the population’s health, for example, breast and bowel screening. We saw the practice website had links to health and wellbeing information.

The practice routinely monitored patient care and treatment to continuously improve it. We saw that the practice had a programme of quality improvement, including 2-cycle clinical and non-clinical audits, to drive improvements in care and treatment.

There were patient registers in place, for example, those with a long-term condition and those with a learning disability. The practice operated a recall system to invite patients for health assessments and checks. The practice had systems in place to follow-up those patients who did not attend their appointments and invited them opportunistically when they attended for other appointments.

The latest published and validated data at the time of our assessment for the period up to end of March 2024 showed that uptake for childhood immunisations for 1-year-olds was 97.3%, 2-year-olds was 83.3% and for 5-year-olds was 82.8%. Clinicians we spoke with told us they followed-up on children not brought to appointments and promoted uptake in consultations.

Validated data for the uptake of cervical screening for the period up to June 2024 for the age group 25 to 49 years was 70.9% and for the age group 50 to 64 years was 75.6%. The practice had systems in place to promote national cancer screening programmes and actively followed-up non-attendance.

Clinicians understood the requirements of legislation and guidance around people’s consent to care and treatment, including the assessment of a person’s mental capacity to make a decision. When needed, clinicians supported patients and involved their families, carers and other professionals to make decisions in the person’s best interests, including decisions about Do Not Attempt Cardio- Pulmonary Resuscitation (DNACPR). We reviewed 2 patient records and saw Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) care plans were used to record patient wishes regarding care and resuscitation and these were stored in the clinical records.

Records showed that Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) training formed part of the practice’s mandatory training schedule.

Staff were aware of the need to request consent to share records in line with General Data Protection Regulation (GDPR) principles.