Northway 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 remains the same.

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

96% of patients that completed the National GP Patient Survey agreed that they felt their needs were met during their last GP appointment which was higher than the local average of 88% and the national average of 90% and 98% of patients felt the healthcare professional they saw had all the information they needed about them during their last general practice appointment which was higher than the local average of 91% and the national average of 92%.

People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. 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. A hearing loop was available. Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing.

The provider had systems in place to identify people with previously undiagnosed conditions. Care plans and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) records were completed and reviewed regularly. 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. Systems were in place to identify individuals with caring responsibilities, who were offered an annual review. All patients with a learning disability were invited to attend an annual health assessment and long-term condition reviews were carried out to those patients who were housebound.

There were appropriate referral pathways to make sure that patients’ needs were addressed. We found that staff had the appropriate skills and training to carry out reviews where appropriate.

The service 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.

Our remote clinical searches identified 12 out of 406 patients with hypothyroidism (a condition where the thyroid does not produce enough hormones) who had not received the appropriate monitoring in the last 18 months. We reviewed 5 of these records and found all had been appropriately recalled. The practice had also taken action in relation to prescriptions to prompt patient engagement and ensure monitoring requirements were addressed.

Our remote clinical search identified 30 patients with asthma who had been prescribed 2 or more courses of rescue steroids in the last 12 months. Of the 5 patients reviewed, we found all were appropriately managed.

Our clinical searches identified 4 patients with chronic kidney disease stage 4 or 5 who had overdue monitoring. We reviewed the records of all 4 patients and found that 3 were being appropriately monitored by secondary care services. The remaining patient had a scheduled appointment in place for blood test monitoring

Our remote clinical search identified the practice had 49 patients with diabetes who’s latest HbA1c (blood glucose) level was consistently high. We reviewed 5 patients and found all patients had been followed up appropriately.

Overall, we found that the monitoring of patients with long-term conditions were in line with National Institute for Health and Care Excellence (NICE) recommendations.

The service 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. There were systems and processes in place to enable information to be shared between the provider and services to ensure continuity of care. Regular meetings were held with multi-disciplinary teams to ensure care was coordinated effectively.

The primary care network (PCN) supported the practice by providing links to pharmacists, paramedics and social prescribers. People were able to receive coordinated care between the practice and the PCN.

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 and patients were encouraged to take an active role in reviewing their health and were given support to recognise changes.

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 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. There were processes in place for annual patient recalls and long-term condition reviews were carried out for those patients who were housebound.

The practice 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 practice had an established programme of clinical and non-clinical audits and action plans aimed at driving continuous improvement in patient care and operational efficiency. For example, we saw audits for Citalopram prescribing in the elderly and hypertension two cycle audits.

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.