Ashfields Primary Care 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 assessed all the quality statements in this key question. At our last assessment, we rated this key question as good. The rating remains good following this assessment.

Feedback from people who used the service indicated that overall, they felt listened to, treated with care and concern and had confidence and trust in the clinical team. Staff involved people in decisions about their care and treatment and provided them with advice and support. Staff worked together and collaboratively with other services to make sure people could access other services easily. Patients received care and treatment that supported them to live healthier lives including being supported to take-up national screening programmes and vaccinations. Clinical and non-clinical audits were carried out as a means to improve outcomes for patients. Our review of the clinical patient record system for the sample of patients whose records we looked at showed that overall, care and treatment had been delivered in line with evidence-based guidance overall. Multi-disciplinary meetings were held on a regular basis where the needs of patients with complex needs or those approaching the end of life could be discussed, reviewed and planned for. The supporting documents following an assessment for ‘Do not attempt cardiopulmonary resuscitation’ were not always available on the patient record system. The provider confirmed the action to be taken to address this in response to our findings.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patient experience of the service as indicated in the National GP Patient survey showed that patients felt involved in decisions about their care and treatment and they had confidence in the healthcare professionals treating them. The practice had systems and processes to keep clinicians up to date with current evidence-based guidelines and clinical tools. There were systems in place to ensure people’s immediate and ongoing needs were assessed. Staff worked with other healthcare professionals to assess people’s needs and deliver coordinated packages of care. There was a system to offer structured annual medicines reviews for patients with long-term health conditions. The provider had systems to identify people with previously undiagnosed conditions. The provider worked with specialist services to review patients with long-term conditions with a view to improving peoples care and treatment and increasing learning amongst the clinical team. Staff and leaders were aware of the needs of the local community. The provider demonstrated that they used registers to identify people with specific needs, for example, people with learning disabilities, mental health conditions, long term conditions, palliative care and carers to ensure that needs were assessed and managed appropriately.Staff and leaders were aware of the needs of the local community and they worked collaboratively and independently to meet these needs. A GP partner was actively involved in a menopause clinic run by the PCN. A heart failure clinic was set up in 2023 and was run by the provider for all PCN patients. In the last 12 months 602 patients were assessed reducing the impact on secondary care and providing a more local service to patients. Extended health checks were provided to asylum seekers that included immunisation history and providing vaccinations as required. A veterans drop-in service enabled care coordinators to assess the needs of patients and sign post them to relevant services.

Systems were in place to ensure staff were up to date with national guidance, evidence-based good practice and required standards. Staff attended regular meetings, training and educational sessions. We looked at the workflow for managing clinical correspondence and tasks and found these were up to date. The experience of people who used the service as indicated in the National GP Patient survey showed that 94% of respondents stated that during their last appointment, they had confidence and trust in the healthcare professional they saw or spoke to. There was a system to ensure people who required monitoring were recalled for checks on their health. Our review of the clinical record system for the sample of people whose care and treatment we looked at, indicated that the results of the clinical searches for the management of patients living with long term conditions were overall good. We identified that improvements were needed to the coding of patients with chronic kidney disease to ensure they received any checks or treatment needed. The provider had already begun a programme of work to address this. They had employed an external service to review patients so that a clear system of coding, review of care and treatment and patient education could be put in place.

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. Leaders and staff worked closely with colleagues in the local primary care network (PCN) to meet the needs of the patient population. Multi- disciplinary meetings were held on a regular basis so that when people received care from a range of different staff, teams or services, this was co-ordinated. However, we noted that shared care agreements between the provider and external services were not easy to access. The provider took action to address this during the assessment.

We found evidence of outstanding practice for this quality statement. The service supported people to live healthier lives and manage their health and wellbeing. The provider had a team of 10 care co-ordinators whose role was to help patients who may need additional support due to illness or vulnerability, such as patients with a learning disability, with dementia, patients receiving palliative care and carers. Patients and their carers could contact the care co-ordinator team directly when they needed support with appointments, prescriptions or referrals. Patients identified for this support were contacted proactively by the care co-ordinator team to see if they needed any help and to check on their well-being. Care co-ordinators signposted and provided information to these patients, for example about local services and health conditions. They recalled patients and provided assistance to encourage attendance at annual reviews. The team worked with other organisations, such as local dementia charities and accessed training and guidance for patients, carers and staff. Staff and leaders told us how they supported national priorities and initiatives to improve the health of the whole patient population, including healthy eating, exercise, smoking cessation and weight management. People living with long term health conditions were referred or signposted to local support services for information, education, advice and support linked to their needs. Members of the clinical team provided patients with information and support to manage their own health, care and wellbeing. People could also be referred to a social prescriber for support with issues impacting on their health such as finance and housing. The provider had run campaigns to improve patient awareness of health issues such as mental health, children’s health and dementia, to promote health screening and to promote services to support patients such as Pharmacy First and 111 Check Your Symptoms.

Leaders demonstrated that monitoring and improving outcomes for patients was important to them and they used information and data to drive improvement. Clinical and non-clinical audits were carried out as a means to improve outcomes for patients. However, we noted that further audits on the effectiveness of the vasectomy service could be carried out. When incidents happened within the service, the provider took steps to rectify these efficiently and to ensure people were satisfied with the outcome. The practice met national targets for cancer screening and immunisations. Patients were encouraged to attend cancer screening and to take up vaccinations offered as part of national programmes. The practice contacted patients who did not attend to encourage uptake of these services. We saw that people were able to get test results and were referred to other services without delay.

People who used the service could make an informed decision about their care and treatment because they had been provided with the information they needed to support them to do so. Staff understood the importance of ensuring that people understood what they were consenting to and the importance of obtaining consent before they delivered care or treatment. Staff had undergone training in the Mental Capacity Act. Leaders and staff understood the requirements of legislation and guidance when considering consent and decision making. We looked at a sample of ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions in patient records. These were not always as required in terms of having the full paperwork available on the patient record system. The provider told us they had taken action in response to our findings.