Albion Health Centre

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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 advice and support.

We rated this key question requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes. Some patients had not received care in line with best practice guidance.

This service scored 50 (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 did not always make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them. Staff had not followed prescribing protocols and guidance to ensure assessments are up-to-date and people’s care needs were routinely reviewed.

As part of the assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. A sample of the records of patients with long-term health conditions were checked to ensure the required monitoring was taking place. These searches were visible to the practice. Patients with asthma who had received the 2 or more courses of rescue steroids and those treated for hyperthyroidism were not monitored appropriately. For example,

• Patients who were coded as having asthma who had two or more courses of rescue steroids in the last 12 months had not received the required monitoring. The CQC search identified one patient with asthma who had two or more courses of rescue steroids in the last 12 months. There was a potential risk of harm to the patient because there was no evidence of an appropriate review or follow up.

• Patients prescribed medicines to treat an underactive thyroid gland (hypothyroidism), had not received the appropriate monitoring. We reviewed patient records and found four patients with hypothyroidism who had not had thyroid function test monitoring in the last 18 months. Their last TSH test was not in normal range and the consulting clinician had not actioned test results for review.

Issues were identified with the management and monitoring of patients with diabetic retinopathy and patients with kidney diseases. For example,

• Patients at risk of diabetic retinopathy had not received the required monitoring. We reviewed patients with diabetic retinopathy who's latest HbA1c was >74mmol/I and found three patients who had not had appropriate monitoring and follow up (diabetic review coded in last 12 months). The patients’ care had not been optimised since blood tests were done and the consulting clinician had not actioned test results for review.

• Patients diagnosed with chronic kidney disease had not received the required monitoring in the last 9 months. We reviewed three patient records and although none of the patients had stage 4 but had stage 3, we found two patients who required renal function monitoring but had not had the required monitoring done.

The provider acknowledged the concerns raised during the recent inspection and took them very seriously. We asked the provider for an action plan detailing the measures to ensure proper management of long-term conditions which included an audit to check patients we identified had been reviewed appropriately. Since our assessment, the service has informed us they have strengthened their systems for managing long-term conditions and reviewed their prescribing policy. Leaders told us the service had held an open afternoon for diabetes education which focused on lifestyle changes, especially diet and exercise. The event was attended by 35 patients. We will review the changes the service has made at the next assessment, to see if they are effective and have become embedded into practice.

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.

Staff described the processes they used to invite patients in for their reviews and action they took if patients did not attend. 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.

The national GP patient survey carried out from January to March 2024 had 110 responses. The patients’ responses for whether their needs were met, was the healthcare professional good at listening to them and were they involved in decisions about their care showed results were below the national and local averages. Data showed that 64%of people completing the survey felt the healthcare professional they saw or spoke to was good at considering their mental wellbeing during their last GP appointment. This was lower than local (71%) and national averages (73%).

The Primary Care Network (PCN) pharmacy team worked on medicines queries and optimising prescribing practices, to make sure they were in line with current guidance. The team also had oversight of long-term condition medication reviews and undertook medicine reconciliation.

The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. Staff told us they had access to up-to-date evidence-based guidance and legislation. However, clinical records we saw demonstrated care was not always provided in line with current guidance. For example, information had not been placed on patient records to ensure that it was safe to continue to prescribe and that the patient received timely care and treatment. There were no protocols which set out the process, or action to be taken if patients did not respond to appointment invites or failed to attend appointments.

Our clinical searches identified concerns related to potential missed diagnosis of patients with conditions such as diabetes. This placed patients at risk of not receiving appropriate management and follow up of their long-term condition and their condition deteriorating leading to irreversible complications.

We found that patients diagnosed with asthma who had required 2 or more courses of rescue steroids (these are medicines to treat an exacerbation of asthma) in the last 12 months, did not always receive a review within 1 week of having the rescue steroid in line with guidelines.Patients with diabetes, chronic kidney disease and hypothyroidism were not monitored in-line with current guidance.

We asked the provider for an action plan detailing the measures to ensure patient safety and proper management of long-term conditions which included an audit to determine if other patients had been reviewed appropriately.We reviewed a sample of both patient learning disability and mental health annual care plans and found they were satisfactory.

Since this assessment, leaders had responded to our feedback about individual patients and identified learning for the wider clinical team. Leaders also submitted a structured quality improvement plan developed to enhance monitoring processes. Weekly failsafe searches were introduced to reduce missed blood tests. The service had subscribed to the Primary Care IT Toolkit software programme to ensure appropriate patient recall and management. These changes will be reviewed at the next assessment.

Staff mostly worked collaboratively to understand and meet people's needs. Staff shared important patient information quickly so that care was well coordinated and patients got the support they needed without delay. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. Leaders told us there was effective communication and coordination within their own service to enable staff to plan and deliver people’s care and treatment.However, we found evidence that records were not always coded correctly, with information relating to medicine reviews and diagnosis. This meant that when people moved in between services, their records were not correct or complete.

There were systems in place to support the effective assessment and treatment of patients with more complex needs. Clinicians attended monthly Integrated care meetings to discuss patients with complex needs. Leaders told us the practice participated in the local Primary Care Network (PCN), where they collaborated on shared service delivery and quality improvement initiatives.

The service supported people to live healthier lives and where possible, reduce their future needs for care and support. Staff said patients had access to social prescribers, health and wellbeing coaches, mental health specialist nurses, and a local weight loss programme. Posters and leaflets were available to direct patients where to seek further advice. The practice had a list of patients who acted as carers for relatives, to enable staff to support them. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

Data from the 2024 National GP patient survey showed that only 52% of people completing the survey felt they received enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses. This was lower than local (61%) and national averages (68%).64%said the healthcare professional they saw or spoke to was good at considering their mental wellbeing during their last general practice appointment.

The provider had processes to monitor people’s care and treatment to continuously improve it. However, they did not always ensure outcomes were positive and
consistent or met both clinical expectations and the expectations of people themselves. There was a system in place to recall patients for long term health condition reviews. The service had administration leads to follow up patients and ensure continuity. However, processes for reviewing the uptake of patient monitoring for long term health conditions needed strengthening. Results from our clinical searches showed there were shortfalls in monitoring long term conditions. There were also shortfalls with ensuring relevant blood tests had been carried out prior to a review or prescriptions being issued.

The provider acknowledged the concerns raised during the recent inspection and took them very seriously. We asked the provider for an action plan detailing the measures to ensure proper management of long-term conditions which included an audit to check patients we identified had been reviewed appropriately. Since our assessment, the service has informed us they have strengthened their systems for managing long-term conditions and reviewed their prescribing policy.

The provider submitted clinical audits which they had carried out to improve outcomes for patients. These included cancer diagnosis audit, an audit of serum lithium level monitoring and an audit of patients of childbearing age (12-55 years) prescribed sodium valproate. Findings from audits were shared with staff to help identify further areas for improvement. At the time of this assessment the service provided minor surgery as a direct enhanced service. The senior GP Partner had carried out a post minor surgery infection audit in 2023 but told us they had not carried out an audit of minor surgery since then.

The provider reviewed the uptake of childhood immunisations and cervical screening. The service had not met the WHO based national target of 95% for five of the childhood immunisation uptake indicators (01 April 2022 to 31 March 2023). However, the service had achieved 90% uptake coverage for four of the five uptake indicators and 85% uptake for one of the indicators. The service was aware of these results and had an action plan to improve uptake. For example, there was a dedicated staff member responsible for reviewing and running the service recall. The service had taken action on providing information to people in the community, about childhood immunisation. They provided unverified data from 1 April 2023 to 31 March 2024 to show they had achieved over 90% uptake for all five of the childhood immunisations.

The service had not met the national target of 80% uptake for cervical screening (NHS Digital data dated 30 May 2023). The service told us that many patients were from black and minority ethnic groups and for cultural reasons did not want to have a cervical smear. The service had a recall system and sent texts to patients with information about cervical screening and a self-booking link.

Leaders told us that following our assessment, the service have updated the practice website to provide accessible information about immunisations to encourage uptake and were trialling new methods of engagement, including educational videos about cervical screening. The practice planned to run an in-practice workshop to inform patients about cervical screening and address any patient concerns. We will review these changes at our next assessment.

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. We saw that consent was documented. Staff gave patients information about care and treatment in a way they could understand and offered appropriate support and time to make decisions. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.