Francis Grove 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 79 (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.

All 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. They also had comprehensive arrangements in place for assessing the needs of carers. When they identified carers a member of staff contacted them to carry out a full assessment of their emotional, physical, and social needs. Support offered included offering them same day appointments and vaccinations at home for the person they care for. They also had robust systems in place to follow up on carers who did not attend for screening invitations.

The practice had a comprehensive approach to managing long-term conditions. Annual reviews were carried out by appropriately trained staff. For example, patients with mental health needs, dementia, or learning disabilities had structured regular reviews of their needs. Efforts were made to maintain continuity of care by ensuring patients saw the same GP where possible. In addition, all housebound patients with long-term conditions were visited regularly and reviewed by the practice paramedic. This ensured their needs were being monitored continuously.

Staff checked people’s health, care, and well-being needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and well-being. 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.

The service always 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. Training was one way that this was achieved. The practice has access to training through South West London Training Hub, and they circulated emails to inform staff of all training that was available. The managers used this to identify training for members of the staff team. For example, learning disabilities and autism training and training for a weight loss injection was identified for all GPs in the practice to complete.

Regular governance meetings were held and during these meetings they discussed all relevant updates. For example, discussing NICE guideline updates. Staff told us there was also a segment in these meetings where they discussed ICB and PCN updates.

Clinical records we saw demonstrated care was provided in line with current guidance. For example, through our clinical searches we saw that the recall system for long term conditions such as diabetes, hypertension, and kidney disease was managing patients well. They had a dedicated team of care co-ordinators who liaised with the lead clinician to ensure these conditions were managed in line with guidance.

They system for identifying and monitoring people with regards to immunisations and vaccinations was in line with guidance and very proactive. For example, their children’s immunisation system was robust. Patients were contacted and invited to appointments by phone and text and multiple follow ups were attempted if they did not attend. The practice was meeting the World Health Organization (WHO) targets for childhood immunisations.

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. They had good working relationships with the district nursing team who could access the duty doctor if they needed to. The GPs also had direct access to the Merton Emergency Response Incident Team (MERIT) who they liaised with very closely. They had monthly multi-disciplinary team meetings with a range of external and internal stakeholders attending (social services, hospice services etc).

Other examples of working with services included working with a local learning disabilities care homes where a clinician visited every week to review 2 patients each visit (so all patients were reviewed every 6 weeks). If there were concerns over a patient the clinician would do a video call to a GP, or the GP would visit. They also liaised with Psychiatry services which was utilised frequently.

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.

The practice made 15-20 referrals to social prescribers each month and they liaised very closely with them to tackle patients at risk. Staff gave examples of positive outcomes for patients with social problems such as homelessness.

Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. The practice used NHS health checks to flag conditions such as obesity and high cholesterol. They also worked closely with a smoking cessation service and provided a room every week in the practice for them to see patients. This service was open to the whole community.

The practice told us they were taking steps to mitigate the lack of weight management services available to their patients. This included arranging for HCA staff to complete a course in healthy weight management so they can work closer with patients.

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.

The practice met national targets for screening and immunisations. Systems were in place to increase uptake and encourage attendance. For example, a dedicated member of staff picked up if a patient did not respond to bowel or breast screening invitations. The patient would be contacted by phone or text and if there was no response they received a letter. Further to this they provided information in easy read format for patients with a learning disability and maintained a register of their transgender patients to ensure the right people were being identified and invited to screenings.

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 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. We reviewed training records and saw that clinical staff had completed appropriate training.

Our review of clinical records confirmed that capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.