The Bucklebury Practice Also known as Chapel Row Surgery

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

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent.

This service scored 75 (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 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 were aware of the needs of the local community and 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 practice shared that they had recently reviewed the care of patients receiving ADHD (attention deficit hyperactivity disorder) medication to check that the prescribing arrangements was safe and in line with practice policy. The recent audit found that patients were receiving appropriate physical health checks, specialist reviews and the correct medication. However, it identified that some shared care agreements had not yet been received or correctly recorded in patient records. The audit outcome suggested the practice had contacted the relevant patients and introduced actions to improve follow-up and record keeping.

Our clinical searches indicated the provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. All patients with a learning disability were invited to attend an annual health assessment.

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

Systems were 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. For example, the remote clinical searches undertaken, showed people on Disease-Modifying Anti-Rheumatic Drugs (DMARDS) received timely monitoring.

The practice carried out a review of patients aged over 40 with raised platelet levels, which can sometimes indicate an underlying health condition. The review showed that most patients had either a clear explanation for the result or had been appropriately assessed, monitored or referred for further investigation. The audit demonstrated that the practice was proactively reviewing abnormal test results and following up patients where needed.

We noted the practice had recently implemented an automated electronic recall system to support the management of long-term condition reviews, as well as recalls for shared care, repeat, and follow-up blood tests.

The practice 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 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.

The practice had a structured process to support patients following discharge from hospital. There were clear processes for escalating concerns identified during post discharge follow up. All patients aged 80 years and over were referred to the social prescriber for proactive follow-up, with younger vulnerable patients referred according to individual needs.

The provider 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, 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.

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.

The practice employed a social prescriber who supported families and carers to assess their ongoing social well-being and practical support needs. The practice has also strengthened support for vulnerable patients by working in partnership with social prescriber.

We noted the provider was part of the Berkshire West Primary Care Alliance Community Wellness Outreach Project, which aimed at increasing uptake of NHS Health checks. Patients were able to find details of this programme on the practice website.

The practice 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 had met national targets for screening and immunisations. 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 nursing team followed up people who did not respond to their screening invitations to encourage improved uptake and also organised weekend cervical screening clinics to increase uptake.

The practice had an established programme of clinical and non-clinical audits aimed at driving continuous improvement in patient care and operational efficiency. For example, there were audits on medical records, chronic kidney disease audits and lynch syndrome audits (a condition that increases the risk of certain cancers, especially bowel and endometrial cancer).

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.

The availability of chaperones was displayed on posters in the practice. Staff who provided this service had completed chaperone training.