Hull Family Practice

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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 remains the same.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 67 (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 did not always make sure people’s care and treatment was effective because they had not always adequately assessed and reviewed their health and care needs. They had effectively assessed people’s wellbeing and communication needs with them.

Feedback from people using the service was mostly positive. People mostly 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 and 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. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing.

The provider had systems to identify people with previously undiagnosed conditions. However, our review of records identified some patients where blood tests indicated they may have diabetes or chronic kidney disease, but the records were not coded as such which meant the patient may miss follow up care. The provider told us they do not code a diabetes diagnosis on the record until the patient has seen a nurse or GP to explain the diagnosis. This process was put in place following a complaint they had received where a patient had seen on their summary records that they had been coded as diabetic prior to their appointment to be told. They also told us they had completed a 2-cycle audit to look at chronic kidney disease and completed more work with their newest practice. They told us they would share this information with the clinical team and will further investigate this to identify any areas for improvement.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. Care for patients with long term conditions was not always provided in line with current guidance.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was mostly provided in line with current guidance. However, patients had not always been reviewed after an exacerbation of asthma and 3 of the 5 patients with asthma we reviewed had not had a recent asthma review. Not all patients with chronic kidney disease at stages 4 or 5 had had all the required monitoring checks completed in the last 9 months however, most were cared for by secondary care providers. Not all patients with hypothyroidism had received thyroid function test monitoring in the last 18 months and one patient had not been monitored since 2018.

Most patients with Diabetes had had the appropriate monitoring checks. The practice had a diabetic nurse, and joint clinics were held with the community team. Staff told us they also worked well with the diabetic team at the local hospital.

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, including where clinical tasks were delegated to other services. For example, the clinical team worked closely with the diabetic community and hospital teams.

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, 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. Staff had lead roles in areas including diabetes and mental health and worked closely with community teams to support patients. Staff had worked to build connections with patients and their carers to ensure a positive response to invites for regular health checks.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. Work to improve uptake of cervical screening and childhood immunisations had not yet enabled the practice to reach the expected targets.

There was a lead member of staff who monitored invites for cervical screening and sent prompt messages to those who did not respond or did not attend. Staff told us they had implemented processes to try to improve engagement with cervical screening. For example, by offering different sites for screening, appointments at extended access services and weekend appointments and they had also implemented self-book invites. Cervical screening data from June 2023 showed 70.4% of those eligible had been screened, the target was 80%.

They had not met the 90% minimum target in 1 of the 5 areas relating to childhood immunisations. They had a lead member of staff who contacted the parents to book appointments and reminders were sent. They told us there was always availability for child immunisation appointments and baby clinics were held weekly. They referred the child to the health visitor if they were not brought for their immunisations.

They kept patients on smoking register details up to date utilising a questionnaire about their health status via a messaging service.

They maintained a register of learning disability patients and had a lead member of staff for this area who worked with patients and carers and arranged annual reviews. Information submitted by the provider showed there were 295 patients on the register and 89.2% had had annual reviews in 2024/25.

They also had a lead member of staff for mental health who maintained a patient register and contacted patients to arrange health reviews. Information submitted by the provider showed 214 reviews had been completed 2024/25 for the 340 patients on the register. They told us they had implemented new systems and reviewed terminology in messages to improve engagement with this group.

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 and had received training in this area. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.