Gravel Hill Surgery

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 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.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs.

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. The service had effective systems to identify people with previously undiagnosed conditions.

We completed remote clinical searches which looked at how well the service conducted reviews for service users with long term conditions where routine tests for safe medicine usage and monitoring were required.

A review of service users with hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone, found that 10% had not had a blood test for their thyroid function test.

All other checks of service users with long term conditions, such as asthma, diabetes and chronic kidney disease, showed all service users had routine tests and monitoring completed or recalls completed in line with clinical guidelines.

A review of disease modifying antirheumatic drugs (DMARDs), which can be given to slow down the symptoms of conditions like rheumatoid arthritis, showed all the correct monitoring and tests had been completed within the recommended timescale.

The practice held a register of carers, which included young carers. The practice aimed to identify patients as carers during new patient registration.

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. The service was a training hub and offered a strong culture of training and development. Meetings were held to support the sharing of information and the practice participated in learning sessions. Staff had access to online training resources as well as access to the local training hub.

Clinical audits and research were completed based on themes and evidence with clear reasoning. They were planned out and shared with the team and the primary care network. An example of a study which the service took part in was the EarLy Surveillance for Autoimmune Diabetes (ELSA) which completed screening on children aged 3 to 13 years for type 1 diabetes (T1D), aiming to review risks of developing T1D in the future.

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 for a consistent process of assessing, planning and delivering people’s care and support. We saw evidence of clear processes and guidance to ensure all staff understood their role.

The service worked with others to ensure people received continuity of care, such as care homes and Primary Care Network Cancer Coordinator. There was evidence of the service working well with other services, such as the local hospice and community groups.

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.

There was evidence of health promotions, such as patient drop in information sessions supported by the Primary Care Network Cancer Care Coordinator and presentations given to the patient participation group.

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.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. We completed a clinical review of different medicines that require regular monitoring, the majority were up to date and completed within the timescale recommended in guidance, those that weren’t had been identified and a plan put in place.

The service had a good understanding of the required screening and immunisation programme and had a plan of work to encourage service users to attend these appointments. Data from the UK Health Security Agency states that the service had achieved the target of 95% of children aged 1 who had completed the primary course of vaccines. Data from NHS England showed 77% of eligible women in the age bracket 25 to 49 years old had an adequate screening test, the expected minimal target is 80%. The service were aware of the importance of encouraging attendance for screening and demonstrated the recall system, and health promotions to improve up take.

Patient feedback was monitored routinely with feedback shared amongst staff weekly via the friends and family test results. Trends and areas of improvement were identified and actions were effectively completed.

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.