Drs T A Underwood & M A Thompson

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

The provider consistently delivered effective, evidence-based care, with people actively involved in decisions about their treatment and support. Care was well assessed, regularly reviewed and coordinated with other services, leading to positive and measurable outcomes. Strong health promotion, innovative programmes and effective monitoring ensured patients were supported to live healthier lives and achieve improved long-term outcomes. 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.

The provider made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

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 had recently implemented a ‘Total Triage’ system to improve access to care for patients. Protocols were in place to support staff in implementing the triage system. For example, where patients were unable to complete the online triage form, they could attend the practice or call in, and a receptionist would complete the form on their behalf.

The provider 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.

Palliative and end of life care patients were reviewed based on national guidance. The provider worked in partnership with other service providers, people and supported their families with up-to-date evidence-based guidance.

Staff who were responsible for reviews of patients with long-term conditions had received specific training.

Clinical audits were conducted to ensure care was delivered in line with legislation and recommended guidelines. For example, the practice operated an in-house weight management and diabetes remission programme called the ‘diabetes second chance’. The practice shared results that indicated that 12% of the patients on the practices’ type 2 register met the formal criteria for diabetes remission with no glucose lowering medication in the last 12 months. This was more than the national remission prevalence of approximately 4.8%. The audit demonstrated sustained remission in many patients while also reducing the need for medication escalation and lowering long term risk of diabetes related complications.

The provider worked well across teams and services to support people.

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, supported by clear governance and communication processes.

We noted that weekly multi disciplinary meetings with local care homes supported proactive care planing, medication reviews and coordinated management for residents. A weekly onsite clinic at a local boarding school supported improved access, wellbeing and care for students.

The provider told us they were introducing a monthly newsletter for all staff through which key messages, changes, learnings, and outcomes would be shared consistently.

Referrals to other services were followed up to ensure that appointments were created for people in a timely manner, for example, when people were referred for suspected cancers.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported national priorities to improve population health, including stopping smoking and tackling obesity, and used social media to promote local and national initiatives.

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. The practice held multi-disciplinary team meetings regularly which enabled continuity of care with other services.

We saw that health promotion materials were available at the practice and staff we spoke to were able to signpost patients to appropriate services to improve or maintain their health. The practice was able to provide appointments with a health and wellbeing coach and a mental health worker, to meet the health needs of its patient population. A community walking group, ‘Walk, Talk, Walk’, had been set up by the practice and was attended by patients and staff every two weeks, to promote the benefits of physical exercise.

Staff were able to refer patients to a Social Prescriber (a non-clinical, NHS-based professional who helps individuals address non-medical needs affecting their health and wellbeing). This service had been very popular, and data provided had shown a high number of onward referrals to social and support services such as food banks, employment advice, dementia support and talking therapies. Feedback for this service was overwhelmingly positive.

The provider 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.

Recent data the practice shared indicated they 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 practise demonstrated a strong commitment to preventive care for patients living with diabetes. They had independently developed and funded a structured diabetes support programme and actively encourage patients to take part in receiving ongoing tailored support for their long term condition management.

Clinical audits were carried out to improve outcomes for patients. This included a two-cycle audit of diabetes management which showed quality improvements in disease control, and in patient understanding and involvement in their own care. The practice had implemented a new recall system for diabetes, designated a clinical lead to oversee delivery of care; and strengthened staff training and competency. The audit results demonstrated increased support with lifestyle changes, consistent prescribing and improved monitoring processes for this patient group.

The provider 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.Staff understood and applied legislation relating to consent. DNACPR decisions were appropriate and made in line with relevant legislation. The provider had undertaken an audit of DNACPR documentation and introduced processes to ensure associated ReSPECT forms referenced in hospital discharge summaries were obtained and saved in the patient record, with evidence of improvement following review.

The nursing team shared examples of seeking consent prior to childhood immunisations.