Coleridge 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 with advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment in April 2023, we rated this key question as Good. We served a Requirement Notice for breach of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Safe care and treatment.

At this assessment, the rating remains unchanged. This key question has been rated as Good.

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.

At our last assessment in April 2023, we found breaches of Regulation 12 – Safe care and treatment.

During this assessment, we found improvements had been made:

Learning disability reviews and guidance documents had improved. Uptake rates for reviews were 58 out of 65 people (87%). Guidance documents had been updated to include the recent learning disability code of practice and training requirements. Staff had attended tiers 1 and 2 of learning disability and autism training. Pictorial letters and invites had been created and there was an action plan to change an area of the waiting room, to provide a quiet space for people with learning disabilities and autism. The service had a policy to offer people with learning disabilities regular annual health checks and reviews; the staff team made personal phone calls to book appointments. This allowed individuals maximum flexibility when planning their appointment, as well as the staff team being able to follow up those who do not attend. Appointments for these people were longer, adjusted, and enabled them to be supported by parents/carers/advocates (where appropriate). Where services were provided to people in a care setting, reviews were scheduled to ensure a co-ordinated approach to avoid care staff having to support multiple appointments with people at different times.

Audits had been completed and improvements made, to ensure people with asthma who required 2 or more courses of rescue steroids had an annual review. Reviews were held opportunistically and on an annual basis. There was a system for pharmacy staff to conduct monthly checks, to monitor recalls and reviews of patients with asthma. A spreadsheet was maintained with a risk rating, so that non-responders could be followed up (or where people had declined a review, this was recorded in their clinical records). The service had implemented a 2 year follow up for people holding steroid cards and provided education around the importance of carrying them. Evidence showed many people had now chosen to keep a digital copy. The service had completed an audit on the use of a specific asthma inhaler, which showed reduced prescribing of these in line with an MHRA alert.

Routine blood testing of people prescribed Disease modifying anti rheumatic drug (DMARDs) medicines had improved. Weekly, monthly and quarterly audits were being completed. These checks were undertaken depending on the date the DMARD was prescribed. A spreadsheet was maintained with a risk rating, so that non-responders could be followed up (or where people had declined a blood test, this was recorded in their clinical records). The service’s pharmacy technician reviewed blood test results on a shared access system (where data and test results from secondary care settings could be viewed), this enabled staff to keep the spreadsheet updated and those who had blood taken in secondary care services, could have their records updated with this data and be appropriately coded.

Uptake rates for cervical screening for eligible patients had improved. The service had applied and been granted permission to complete the NHS England SW Cervical Screening Uptake Improvement Project, in line with thenational cervical cancer elimination strategy for England. The aim of the project was to increase uptake rates for eligible people aged 40-44 and over 55 years old, who were severely overdue/non-responders to screening requests (which was up to 45% of the service’s overdue population). The project began in March 2025 and is due to be completed by the end of December 2025. Latest national data (dated 30 June 2024) showed that 81% of eligible people had received cervical screening and the percentage of the eligible population aged 25 to 49 years old was 77.5% compared to the national target of 80% (which was previously not recorded as a data set). Unverified data from the service showed an uptake rate of 80.3%. To improve uptake rates the service had dedicated admin member of staff for cervical screening, who managed prior notifications and ceasing recalls (where appropriate). Reminder messages were sent to all eligible people who had their first invite 4 months ago, with a booking link so they could book a screening appointment without having to phone/come into service to book. If the person then doesn’t attend, they will be recorded as a non-responder, in these instances the staff member would ring the patient to book an appointment and answer any concerns they may have. If people declined at this point and requested that screening invites were not sent to them again, relevant paperwork was completed and clinical records coded accordingly, with the persons understanding that they could remove this decline at any point. The service had trained 2 members of the nursing team to be able to perform cervical screening, increasing availability / capacity for patients.

Feedback from people using the service was mainly 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.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.