Dr Jefferies and Partners

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 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.Staff worked together and worked well with other organisations to deliver effective care and treatment. At our last inspection, we rated this key question as good. At this assessment, the rating has remained the same.

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 practice had systems and processes in place to identify people’s needs and preferences during the registration process. Leaders and staff told us they 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. Although during the inspection we found that the correct search codes were not always being applied in the clinical system. However, the practice could still evidence appropriate and timely medication reviews were being undertaken. 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. Systems were in place to identify people with caring responsibilities at registration, opportunistically, and through self-reporting. They held a carers’ register and ensured the information was up to date.

The practice 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. The practice held registers for patients and provided annual health checks for those with learning disabilities, people with severe mental health conditions, palliative patients, and vulnerable patients.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The service worked well across teams and services to support people. Management informed us they used appropriate coding when moving children to adult services. There were established pathways for staff to follow to ensure patients’ needs were met.

The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. The processes in place enabled staff to liaise regularly with community teams such as community nurses, health visitors, and palliative care nurses. Staff told us regular multi-disciplinary team meetings were held with external agencies where vulnerable people, or those receiving end-of-life care were discussed and actions recorded.

The practice supported people to manage their health and well-being 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. Patients had access to a social prescriber, which helped them improve their health, well-being, and social welfare by connecting them to community services. Healthy living information was available on the practice website, digital information screen in the waiting room and leaflets in waiting area.We saw the practice website had links to health and wellbeing information.

Staff supported national priorities and initiatives to improve population health, which included stopping smoking and tackling obesity.Staff gave examples of where people had been positively supported to live healthier lives, which included healthy eating, weight management, and wellbeing talks. Arrangements were in place to offer people with a learning disability and people with a severe mental illness an annual health check. No concerns were raised by those using the service about supporting people to live healthier lives. We found no concerns regarding processes to help support people to live healthier lives.

The practice routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive, consistent, and that they met both clinical expectations and the expectations of people themselves. The practice submitted a range of clinical audits that demonstrated quality improvement such as post gestational diabetes monitoring.

The practice performed below the national target in relation to childhood immunisations and cervical screening. For example 61.5% of children aged 5 had received 2 doses for Measles, mumps, and rubella (MMR) and the World Health Organisation (WHO) recommends a rate of 95%. Additionally, the cervical cancer screening rate for 25 to 49 year olds was 46.4 % and screening rate for 50 to 64 year olds was 55.5 %, but the national target rate for both is 80%.The practice was aware of this and provided evidence for improvement as they were actively call-and-recalling patients, if patients declined the nurse would follow up with a phone call and staff offered opportunistic immunisations and smears. Despite the practice’s efforts uptake remains below national target.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. The service told people about their rights around consent and respected these when delivering person-centered care and treatment. Clinicians supported patients in making decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision. We reviewed five patients’ Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions and found they were made in line with relevant legislation and were appropriate. Staff had completed mental capacity act training.

Staff who carried out chaperone duties were trained for the role and had received a disclosure and barring (DBS) check at the appropriate level. Posters were displayed in the practice informing people this was available to them. There were no concerns were raised by those using the service about consent to care and treatment.