Church Lane 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

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Clinical record reviews indicated that most patients experienced positive outcomes in line with legislation, standards, and evidence-based guidance. However, the provider did not have robust systems in place to identify individuals with potentially undiagnosed conditions. For example, diabetes and uptake of national screening programmes for cervical cytology and childhood immunisations was below national standards. Staff made sure people understood their care and treatment to enable them to give informed consent. Where individuals lacked the capacity to make decisions, staff engaged those who were important to them to act in their best interests.

This service scored 71 (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. 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.

Feedback from people using the service was largely positive, reflecting a high level of satisfaction with the care and support provided. People felt involved in assessments of their needs. The National GP Patient Survey data showed 98% of patients felt as involved as much as they wanted to be in decisions about their care and treatment (national average 91%). Reception staff demonstrated an awareness of the needs of the local community and staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. The practice had a Social Prescriber who attended the practice once a month to supported patients with social, emotional and practical needs to support their overall health and wellbeing.

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. For example, our clinical searches identified 91 of the 831 patients diagnosed with diabetes had a HbA1C (blood test to check glucose levels) above 75 mmol. We reviewed 3 records, and all had received a comprehensive review including a review of their medicine. The practice had a system to recall, review and monitor patients with a long-term condition at regular intervals. For example, of the 39 patients diagnosed with chronic kidney disease stage 4 and 5, three had not received a monitoring blood test in the previous 9 months. We reviewed these records, and all were under the hospital for follow up.

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.

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 some risks to patients’ health, including those in the last 12 months of their lives, and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The service did not consistently monitor people’s care and treatment to drive continuous improvement. Performance data indicated that the practice was below national targets for cervical screening and childhood immunisation uptake. Specifically, the practice had not met the World Health Organisation (WHO) target of 95% for childhood immunisations, nor the national standard of 80% for cervical cytology. Uptake for cervical screening from the most recently published public health data was 66.1% for patients aged 25 to 49 years, and 71.3% for those aged 50 to 64 years.

In response, the provider reported that Care Coordinators actively contacted patients who missed appointments for their cervical cytology screening. A patient survey conducted 2 years ago identified 20% of respondents cited difficulty in securing appointments at convenient times. As a result, the practice introduced lunchtime appointments and increased the number of staff trained to carry out cervical cytology. Additionally, they implemented a system where reminder text messages included a direct booking link, removing the need for patients to call the practice.

The provider also acknowledged low uptake of childhood immunisations. They told us some children had received vaccinations abroad but lacked documentation. Following internal review, the practice planned for a GP to contact parents of children who had not attended for immunisations to discuss concerns. They also intended to use TV screens in the waiting area to promote immunisation awareness.

Clinical record reviews indicated that most patients experienced positive outcomes in line with legislation, standards, and evidence-based guidance. However, the provider did not have robust systems in place to identify individuals with potentially undiagnosed conditions. For example, clinical searches identified 35 patients with a possible missed diagnosis of diabetes. Of the four records reviewed, 3 had a potentially missed diagnoses of type 2 diabetes. A separate search for chronic kidney disease (CKD) stages 3, 4, or 5 identified 236 potentially undiagnosed patients. The GP confirmed awareness of this issue and stated that patients were being reviewed opportunistically to confirm diagnoses and provide appropriate care.

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. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. Where individuals lacked the capacity to make decisions, staff engaged those who were important to them to act in their best interests.