Noakbridge Medical Centre

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. People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was mainly based on latest evidence and good practice, however systems to ensure evidence-based decision making could be strengthened. 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. Staff involved those important to people took decisions in people’s best interests where they did not have capacity.

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.

Overall the practice made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. However patient experience was below local and national averages and assessing the needs of people living with some long-term conditions required strengthening.

Feedback from people using the service was generally positive. National GP patient survey results were 71.7% for the percentage of respondents who stated the last time they had a general practice appointment the healthcare professional was good or very good at listening to them. This was below the national average of 86.7%.

The percentage of respondents to the GP patient survey who responded positively to the overall experience of their GP practice was 51.6%. This was below the national average of 73.9%.

Reception staff were aware of the needs of the local community. 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. However, there were gaps in some areas. For example, where patients experienced an acute exacerbation of asthma, they were not always followed up in line with national guidance. Our clinical searches identified 240 patients with an asthma diagnosis. Ten patients had been prescribed 2 or more courses of rescue steroids. We reviewed 4 patient records and found concerns with 3 records. Three patients were not offered a steroid emergency card. Steroid cards may be issued in various clinical setting, including hospitals, however the practice did not have systems in place to review these as part of their medicines review processes. During the inspection leaders took immediate action to review internal and external systems to improve continuity of care for patients. In addition, not all patients living with hypothyroidism had timely monitoring for their condition. Leaders told us that patients did not always respond to requests for reviews. Our searches identified 192 patients living with diabetes. We reviewed 2 patient records and found high quality diabetic annual reviews had been undertaken by the Practice Nurse.

Leaders told us the clinical searches had identified the approach to recall for patients with long term conditions was not always effective. They planned further training for practice staff and to implement and embed effective arrangements.

Registers were kept of patients’ different health requirements. The practice employed a care coordinator through the Primary Care Network (PCN) who managed the registers and invited patient to the practice for reviews and health checks according to their needs. Leaders told us the practice had exceeded the allocated target of health checks over the last two years and there was a system in place to identify the highest priority groups.

We observed there was a wealth of health and social prescribing information for patients in the practice waiting area. Self-help advice tools were available to patients on the practice website.

The practice identified patients with caring responsibilities. There was a carers policy that detailed how the practice identified carers, which included patient information on notice boards, and as part of new patient registration checks. Staff told us they proactively identified carers as part of their conversations with people.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber who was employed by the local Primary Care Network (PCN). They worked in the practice 1 day a week. We spoke with the social prescriber who was able to describe how their role supported people and assess their needs. For example, they supported people who required reasonable adjustments for their mental health challenges and supported people to book appointments to meet their individual needs.

Staff told us they planned and delivered people’s care and treatment with them, including what was important and mattered to them. However, we found that systems required improvements in some cases to ensure effective monitoring of patients care and treatment. We found long term condition monitoring required strengthening to ensure patients were monitored effectively. This was not always done in line with legislation and current evidence-based good practice and standards.

The service always worked well across teams and services to support people. Leaders and staff worked closely with colleagues in the local Primary Care Network (PCN) to meet the needs of the patient population. For example, the practice worked within a multi-disciplinary approach with services to support the frail, elderly and vulnerable population as part of Basildon Early Response Team (BERT). The service offered a range of services, which included same day home visits, home visits for people who had been discharged from hospital and welfare calls. The team included GP’s, social prescriber and care co-ordinators, district nurses, occupational therapist, social workers, palliative care and mental health support teams. The team measured outcomes for people and data demonstrated a 44% reduction in hospital admissions for patients who had accessed this service. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support.

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, 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.

The practice employed a care co-ordinator and social prescriber, whose roles were to help patients who may need additional support due to illness or vulnerability. This included patients with a learning disability, those living with dementia and patients receiving palliative care. Patients identified for this support were contacted proactively to see if they needed any help and to check on their well-being. The care-co-ordinator encouraged attendance at annual reviews. The team worked with other organisations, such as dementia teams and the voluntary sector. Staff told us they worked with local leisure services and referred people living with cancer to a 10-week structured exercise and wellbeing programme.

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.

However, the practice had not met all the national targets for screening and immunisations. We reviewed the practice performance for indicators including prescribing safety, prevention, diagnostics and access. We found cervical screening uptake was reported at 75.3% which was below the national target of 80%, this was a trend over time. The practice was aware of this and had an implementation plan in place, which included a tailored approach to discuss barriers to screening. The practice shared the findings of an audit of cervical screening uptake, April 2025 whose aim was to achieve a target higher than the 80% target and included an action plan. Staff provided supportive material to families to help educate the benefits of childhood immunisations.

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. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.