Cumberland House Surgery

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• 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.

We found that staff involved people in decisions about their care and treatment and provided them advice and support. Staff worked together and collaboratively with external health and social care providers 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 undertake national screening programmes and vaccinations. Patients who required monitoring underwent regular checks on their health. Clinical and non-clinical audits were carried out 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. 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 document for a 'Do not attempt cardiopulmonary resuscitation' decision that was made by secondary care was not always available on the patient record system. The provider took immediate action to address this following the assessment.

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.

We found examples of outstanding practice in how the provider assessed people’s needs. People’s experience of the service as indicated in the National GP Patient survey showed that 91% of patients (national average 91%) felt involved in decisions about their care and treatment, 86% (national average 87%) felt the healthcare professional was good at listening and 91% of people (national average 90%) reported that their needs were met. Recent NHS website reviews (these reviews were unvalidated by CQC) showed that patients felt they were listened to in their consultation and given the time they needed. 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 used registers to identify people with specific needs, for example, people with learning disabilities, mental health conditions and carers to ensure that their needs were assessed and managed appropriately. Patients who lived in care homes had weekly or bi-weekly ward rounds with the same GP so that continuity of care was promoted and their health needs were monitored. The practice assessed the needs of housebound patients and developed a holistic management plan. Frequent hospital attenders were identified and reviewed in an extended appointment to optimise their care and support and to minimise further hospital admissions. Health assessments of carers were carried out to support their health and wellbeing. The practice had set up a women’s health clinic which was extended to all people across the PCN and allowed women to receive a specific assessment for conditions such as the menopause.

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. 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 health monitoring of a very small number of patients with long term conditions. Also to ensure a timely follow up to check patients responses after asthma treatment. During the assessment the provider took immediate action to address this by updating procedures, patient records and recalling patients for a review.

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. The practice had established a women’s health clinic to support and work with the PCN to enhance patient care and GP practice collaboration. 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. The safeguarding lead had set up peer support group meetings for the safeguarding leads in the PCN to discuss topical issues and learning and they acted on any issues identified to make improvements.

The service supported people to live healthier lives and manage their health and wellbeing. 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 smoking cessation and weight management. People living with long-term health conditions underwent regular monitoring. They 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 where possible. People were also encouraged and supported to make healthier choices to help promote and maintain their health and wellbeing and prevent deterioration. People could be referred to a social prescriber for support with issues impacting on their health such as social isolation, life changing events and housing. A care-coordination service also provided support, including support following hospital discharge, transport to hospital and medical related referrals. On behalf of the PCN, educational events for patients to improve awareness of issues such as men’s mental health and menopause had been presented by the practice to patients living in Macclesfield registered at all practices. The practice worked with the PCN to provide a ‘Full Circle Programme’ that supported people at every stage in their lives by working with local health and care services, advertising these services and supporting people to access them.

Leaders demonstrated that monitoring and improving outcomes for patients was important to them. Clinical and non-clinical audits were carried out to improve outcomes for patients. When incidents happened within the service, the provider took steps to rectify these and to ensure people were satisfied with the outcome. The practice met national targets for childhood immunisations and cervical screening uptake. 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. The provider was actively participating in a 'Very High intensity User' programme, (supporting people who attend secondary care services more than expected) with the largest uptake across the PCN, with the aim being to reduce hospital attendances and improve patient experience, care and treatment.

Feedback from the National GP Patient Survey showed 91% of patients felt involved in decisions about their care and treatment. People were provided with information about their care and treatment to enable them to make an informed decision. 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 to enable them to understand 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. The supporting document for a 'DNAR' decision that was made by secondary care was not always available on the patient record system. Following the assessment the provider addressed this by revising the policy and procedure and auditing all records to ensure the correct information was accessible.