Dearne Valley Group Practice

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

At our previous assessment in March 2016, we rated the practice Good for providing effective services. At this assessment we have rated the practice as Requires Improvement.

We found that patients’ needs were not always assessed, and care and treatment was not always delivered in line with current legislation, standards and evidence-based guidelines. There was not effective coding of patients with diabetes, which meant we did not have assurances their individual needs were being met. Clinical searches identified patients with long term conditions such as asthma or hypothyroidism were not receiving structured reviews all of the time. We found some patients were not receiving the correct monitoring within the appropriate timescales.

Managers told us that at the direction of their local ICB they used a clinical search system called Eclipse. However, this did not always identify patients requiring regular monitoring or follow up, such as those with long term conditions or prescribed high risk medicines. We expect all GP Practices to have systems in place to review these patients in line with best practice guidance.

We found that staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people who took decisions in people’s best interests where they did not have capacity.

This service scored 58 (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 that, although there were systems and processes in place to ensure there was care and treatment of patients, they needed reviewing to ensure patients received effective care. Through our clinical searches we ran, we found that medicines management did not always reflect current and relevant best practice and patients care needs were not always reviewed. We reviewed a patient who was taking topiramate (a medicine used for treating epilepsy) and found that there had not been a medicine review recorded in the last 12 months, it also was unclear whether the risks of taking this medicine had been explained as it was not documented. Searches identified 22 patients with a potentially missed diagnosis of diabetes, we looked in detail at 3 patients records and found issues with coding these patients as diabetic. Therefore, we could not be assured that the needs of these patients were being met. We found that reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

We found that the practice had some systems in place to ensure patients received care and treatment in line with guidance. However, we found that these systems did not always ensure effective monitoring of patients care and treatment. Clinical searches found that people with long-term conditions were not always offered a structured annual review to check their health and medicines needs were being met. Searches of patients with asthma who had been prescribed 2 or more courses of rescue steroids, identified 53 patients. We looked at 3 records and found that 2 of these patients required steroid cards. We also identified 76 patients with hypothyroidism had not received a thyroid function test within the last 18 months, which was not in line with National Institute for Health and Care Excellence (NICE) recommendations. Following the assessment the provider put on extra phlebotomy clinics to ensure the remaining of these patients received the required monitoring.

Remote searches also identified 22 patients with a potential missed diagnosis of diabetes. We reviewed 3 patient records and although they were receiving the right care and treatment, they were coded incorrectly which meant there was potential for these patients to be missed from specific recalls which would affect their future care and treatment.

The service did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services. We found that safeguarding arrangements required strengthening between the provider and their local authority as the practice’s safeguarding list was not being reconciled. Therefore, we did not have assurances that these were being managed and reviewed effectively, and that the practice was not working as well as they could with other teams to safeguard people.Following the assessment the provider had engaged with their local authority however they found that they did not have processes in place to align their safeguarding register with the practice.

We saw there were effective systems in place to manage two-week wait referrals and that blood and test results were dealt with efficiently. The practice did a regular blog where information was shared across teams. Staff feedback highlighted that this was a positive way of passing information and changes around the practice.

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. The practice operated a red, amber, green process for identifying these patients. They were also given a direct contact number to a care coordinator. Staff supported national priorities and initiatives to improve population health, including stopping smoking, diabetes prevention programme and tackling obesity.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. We found inconsistent approaches to monitoring people’s care and treatment. Remote clinical searches showed not all patients had received annual reviews and were not being appropriately monitored to ensure their high-risk medicines and long-term conditions were regularly reviewed. For example, we found patients were identified who had a potential missed diagnosis of diabetes. Patients with hypothyroidism who did not routinely have regular thyroid function tests.

The practice had completed some quality improvement work, this included an audit on patients with heart failure. The latest data available showed that the practice had achieved 71.2% of cervical screening, this is below the national target of 80%. The practice provided us with their current cervical cancer screening rates which had improved to 75%. Latest data available showed that the practice was achieving over the national target of 95% for 3 of the 5 childhood immunisation targets. Data available showed that the practice was on an upward trajectory and their immunisation rates had been improving each year.

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. The practice had a consent policy and staff had completed mandatory training on this. We also saw information available to patients on this at both sites. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.