Ombersley Medical 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 looked for evidence 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.

Staff 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 staff understood their individual and cultural needs. 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. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. The practice used a specialist programme which was used on patients records to identify people who would benefit from social prescriber. This helped to ensure more people received additional help and support.

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. Clinical records we saw demonstrated care was provided in line with current guidance.

Staff always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once. Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. Referrals reflected people’s circumstances and preferences.Leaders and staff had developed strong working relationships with other services so they could follow up with phone calls and emails to ensure people were receiving continuity of care, including where clinical tasks were delegated to other services.

Staff supported people to manage their health and wellbeing to maximise their independence, choice and control. They supported people to live healthier lives and where possible, reduce their future needs for care and support.Staff focused 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.

Leaders and staff monitored people’s care and treatment to continuously improve it. They ensured outcomes were positive and consistent, and they met both clinical expectations and the expectations of people themselves. From the clinical notes we reviewed, we found people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. Staff routinely followed up when childhood immunisations were missed with phone calls to ensure parents had the opportunity to discuss this. Leaders reported they had a high uptake for adult vaccinations such as flu and covid with only 6% of people declining to have this done. Staff followed up adults who had not booked in for screening. For example, if a patient had not completed the bowel screening, they were contacted, and the discussion was recorded in the patient’s records. However, the practice did not have a cytology failsafe in place. This was a process for ensuring cervical smear testing was followed up in line with national guidance. We raised this with leaders who addressed this immediately and put a process in place for designated staff to use.

Staff told people about their rights around consent and respected these when delivering person-centred care and treatment. Staff recorded capacity and consent discussions they had with people. We saw in the records staff used the 5 key guiding principles for best interest decision making using the Mental Capacity Act 2005.Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.