Gosberton Medical Centre

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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 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 has changed to outstanding. People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff made sure people understood their care and treatment to enable them to give informed consent.

This service scored 88 (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. Staff had a good awareness of the needs of the local community and were knowledgeable on additional support they could offer. 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.

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.

They offered face to face and telephone appointments and home visits where needed. They also offered double slot appointments to those with additional needs.

Staff told us that the social prescriber completed a tutorial with all new staff, so they were aware of the social prescriber role and the criteria for referring patients to them.

The practice is a carer’s accredited practice. Carers were offered priority access at the surgery and appropriate adjustments were made where needed.

Patients with long-term conditions, dementia, learning disability and mental health needs receive personalised care plans following assessment. To support shared decision making, copies of care plans were given to patients. Following their annual health check, patients with a learning disability were given “grab and go” hospital passports, ensuring assessed health, communication and care needs were clearly documented and easily available to support continuity.

The practice was Veterans Friendly accredited and identified veterans at the point of registration and through routine reviews, holistically assessing any additional needs associated with military service.

Capacity and access needs were continually monitored. When routine waits were longer than one to two weeks, additional clinics were provided to ensure timely assessment for patients.

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. However, we found that the follow up of patients after an acute asthma attack within an appropriate timeframe was inconsistent. The provider took action to address this immediately after our assessment.

The service worked well across teams and services to support people. They shared 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.

The PPG spoke positively about how the practice worked with them to make improvements.

Staff reflected the benefits of how the practice worked as a team to support people. There was evidence of working with wider health care teams through a range of MDT meetings. Patients had access to services provided by the local PCN, including social prescribers and care home rounds. Support and learning was shared across the PCN.

Additionally on-site Health Visitor clinics were available, enabling coordinated support and information sharing. There was a focus on providing co-ordinated in-house care covering physical and mental health and social needs through the range of services available and collaborative working by the practice staff, health and wellbeing coaches, mental health nurse and social prescriber as well as with external partner organisations and teams.

The service always supported people to manage their health and wellbeing to fully 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. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The practice had established a local wellbeing hub with a variety of support groups for patients to access and help them to manage and improve their health and wellbeing.

There was a smoking cessation clinic held at the practice. We were given examples of how the holistic approach taken by the practice had led to early cancer diagnoses.

The practice had set up a respiratory support group and supported the practice nurse to develop advanced skills in ChronicObstructivePulmonaryDisease(COPD) and asthma in order to improve management of these conditions. They had also purchased a FENO (Fractional Exhaled Nitric Oxide) machine (used to aid in the diagnosis of asthma) to enable patients to access this service locally and in a timely way.

The practice had worked with the Integrated Care Board’s vaccinations team to implement strategies to address patients’ hesitancy for vaccination and improve uptake which included training for all staff.

The service monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

National data showed that all 5 indicators for childhood immunisations had achieved the minimum 90% uptake target, with 4 of the 5 having achieved the 95% World Health Organisation based target for uptake and had been consistent over time. National data showed the uptake of cervical screening for the eligible population aged 50-64 was above the national target of 80%.

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 practice carried out their own audits to monitor and improve care as well as participating in local and national audit activities.

The service always carefully explained to people what their rights around consent were, made sure they fully understood them and always fully respected these when delivering person-centred care and treatment.
Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded.

Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.

Following an area that had been highlighted at our previous assessment, one of the GP partners led discussions at PCN level relating to completion of ReSPECT forms. They worked with a palliative care consultant to contribute to a refresh of the Lincolnshire wide ReSPECT policy which resulted in simplification of clinical authorisation and the introduction of a standardised template in care settings.

The in-house Neighbourhood Nurse carried out capacity assessments and supported RESPECT (Recommended Summary Plan for Emergency Care and Treatment) form completion, enabling informed care and end-of-life decisions. RESPECT forms were regularly audited and staff received regular training in this area to ensure information relating to patients wishes was accurate, valid and easily available.

The practice had a higher-than-average LGBTQ+population and staff had identified a need for sensitive discussions about birth gender screening. As a result, staff members attended targeted NHS training, following which the practice introduced rainbow signage, gender-neutral toilets and same-gender chaperones. This created a supportive environment, enabling patients to give informed consent without fear of discrimination.