Belmont 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 that staff involved patients in decisions about their care and treatment and provided them with advice and support. Staff routinely reviewed patients 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 practice had systems and processes in place to identify patients’ needs and preferences during the registration process. The practice 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 patients’ health, care, and wellbeing needs during health reviews. Clinicians used templates when conducting reviews to support the assessment of patients’ wider health and wellbeing. Staff could refer patients with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

Leaders told us about initiatives they were implementing to improve the continuity of care for vulnerable patients. This included allocating patients over 75 years of age with 4 or more co-morbidities to a care co-ordinator who will be the first port of call for these patients for any medical or administrative needs. The care co-ordinators will also provide care navigation for these patients as they get to know them and assess their needs.

The practice had effective systems to identify people with previously undiagnosed conditions. Clinical searches identified 12 patients with a potentially missed diagnosis of diabetes. We looked in detail at 5 patient’s records and found that all 5 patients had received the required reviews and had been coded on the clinical system appropriately.

The vast majority of feedback from patients using the service was positive. The National GP Patient Survey found 90% of patients felt their needs were met during their last general practice appointment.

There were systems in place to ensure staff were up to date with relevant legislation, evidence-based practice and required standards. Clinical meetings were in place to keep staff up to date. For clinicians who were unable to attend this meeting in person, clinicians were able to join the meeting remotely if needed. These meetings were also minuted and disseminated to all clinicians.

The remote clinical searches we undertook of the practice’s clinical records system included reviewing the monitoring of people with long-term conditions to assess if National Institute for Health and Care Excellence (NICE) recommendations were followed.

For example, we identified 105 patients with diabetes whose last blood glucose reading was over 75. We reviewed a random sample of 5 patient records and found all patients had their diabetes and diabetic medication reviewed following this blood glucose result.

One of our clinical records searches reviewed the number of patients with asthma who had been prescribed two or more courses of rescue steroids in the last 12 months. We identified a total of 46 patients and reviewed a random sample of 5 patient records and found all patients had been followed up appropriately and had received an adequate annual asthma review which included providing the patient with an asthma care plan.

For patients with hypothyroidism (an underactive thyroid), our clinical records searches identified 11 patients who had not had thyroid function test monitoring for 18 months and we reviewed a random sample of 5 patient records. We found the practice had identified these patients were overdue monitoring and had already taken steps to address this.

The practice worked well across teams and services to support patients. They made sure patients only needed to tell their story once by sharing their assessment of needs when people moved between different services. Staff had access to information they needed to assess, plan, and deliver patients’ care, treatment, and support. Systems were in place to share information about patients electronically with other services.

The practice worked with other services to ensure continuity of care and engaged in multi-disciplinary team (MDT) meetings. For example, a community midwife provided weekly antenatal clinics for patients and weekly appointments were available for patients with a primary care mental health worker. The practice referred patients to the additional roles reimbursement scheme (ARRS) wellbeing team for appointments with health and wellbeing coaches and social prescribers. The ARRS pharmacist and pharmacy technicians provided both telephone and face to face appointments for patients for advice and support with their medicines management.

First contact practitioner (FCP) physiotherapy was available for patients with musculoskeletal (joint, muscle, or nerve) pain to have appointments with a physiotherapy directly at the practice.

For patients identified as approaching end of life, the practice referred to and worked closely with the community palliative care team. Home visits and care packages were implemented to ensure patients’ wishes were followed and carried out in their final stages of life.

The practice supported patients to manage their health and wellbeing to maximise their independence, choice and control. Staff supported national priorities and initiatives to improve population health, including stopping smoking, diabetes prevention programme and tackling obesity. For example, staff had received training to offer patients “Swap to Stop" advice and kits. “Swap to Stop" is a national NHS initiative providing free vape kits and support to help adult smokers quit cigarettes in England.

Staff told us they undertook proactive telephone calls to patients at high-risk of coronary vascular disease to encourage them to attend health checks.

For patients experiencing chronic pain, the practice had set up chronic pain educational sessions to help them manage their condition.

The practice produced a monthly newsletter for patients which contained information to support health initiatives, and the practice website provided a wide range of health information.

Staff told us the practice had future plans in place to further support patients to live healthier lives. These included supporting the set up of a dementia café and offering chair yoga sessions to support frail patients with strength training exercises.

The practice routinely monitored patients care and treatment to continuously improve it. Staff endeavoured to ensure that outcomes were positive and consistent, and that they met both the clinical expectations and the expectations of patients. 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.

Published national data showed the practice had achieved the World Health Organisation 90% minimum targets for 4 out of 5 childhood immunisations. The percentage of children aged 5 who had received immunisation for measles, mumps and rubella (two doses of MMR) was 88%.

Published national data for the uptake of cervical screening showed the practice had achieved 76%, which was slightly below the national target of 80%. The practice was working to improve the cervical screening uptake, and staff told us they made telephone calls to patients who failed to attend their appointments.

The practice undertook regular clinical audits, and we were provided with evidence of two-cycle audits which demonstrated quality improvement. From the clinical records 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 practice told patients about their rights around consent and respected these when delivering person-centred care and treatment. A consent policy was in place to ensure appropriate consent was obtained from patients when receiving care and treatment. Staff understood the requirements of legislation and guidance when considering consent and decision making.

Patients were offered a chaperone for care and treatment when this was appropriate. Chaperone posters were on display at the practice to inform patients of this service and staff who provided this service had completed chaperone training.