Pontesbury & Worthen Medical Practice

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.

This service scored 67 (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.

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 needs. This was also reflected in the national GP survey where 97% of practice respondents said they were involved as much as they wanted to be in decisions about their care and treatment during their last appointment. In addition, 98% of respondents felt their needs were met during their last appointment. Both indicators were higher than the local and national averages.

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. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. 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 via their primary care network (PCN).

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

During the remote clinical review, we carried out a search to identify people with asthma who had been prescribed 2 or more courses of rescue steroids in the past 12 months. The search identified 22 people. We reviewed a random sample of 5 clinical records and found all 5 had been followed up as per the recommended guidelines.

Further reviews of the clinical system identified people with diabetes who had a HbA1c of 75 and over. A haemoglobin A1C (HbA1C) test is a blood test that shows the average level of blood glucose over time. We reviewed a random sample of 5 clinical records and found the appropriate reviews had been completed.

Our remote clinical search identified the practice had 5 patients with hypothyroidism who had not had a thyroid function test monitoring for 18 months. We sampled 5 of these patient records and found all 5 patients had been recalled by the practice.

Our clinical searches identified 45 patients with chronic kidney disease stages 4 or 5. We sampled 5 patient records and found all had received the required blood monitoring to assess their kidney function in the previous 9 months.

Systems were in place to encourage staff to keep up to date with evidence-based guidance and legislation including formal and informal clinical meetings, attendance at protected learning days and in house text message group. However, guidance was not always followed for example we found incorrect signing of prescriptions and checking of controlled medicines.

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.

The practice was part of the Shropshire Rural Alliance Primary Care Network (PCN), a group of 5 local GP practices supporting approximately 30,000 patients in and around rural Shropshire. The PCN provided supporting roles including a pharmacy team, first contact physiotherapists and home visiting paramedics.

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. Multi-disciplinary meetings were held every 6-8 weeks to discuss any change in needs.

Staff supported national priorities and initiatives to improve population health. The provider offered access to a digital platform that empowered patients to manage their wellbeing remotely and receive personalised support beyond traditional consultations.

The practice monitored people’s care and treatment to improve it.

A review of the most recently published data for cervical cancer screening showed the practice had achieved an uptake of 74.8% within the last 3.5 years for their eligible population aged 25 to 49 years old and 77.2% uptake within the last 5.5 years for their eligible population aged 50 to 64 years old. These were below the national target of 80%. The practice had attempted to improve on the cervical screening uptake through a variety of ways, including offering appointments on a Saturday, at their branch site.

The practice had met the World Health Organisation based target in all 5 childhood immunisation indicators. The practice had arrangements in place to follow up immunisation appointments when a child was not brought, or the appointment cancelled and not rebooked. Staff offered as much flexibility as possible to enable patients to attend their immunisation appointments.

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. We checked the records of 5 patients who had ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) forms completed. There were systems in place to monitor and manage completed forms and decisions and preferences regarding advanced end of life had been recorded including patients, families and multi-disciplinary outcomes.