Enderley Road 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 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 inspection in 2018, 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 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 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. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. 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.

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.

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.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control.

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 service supported people to live healthier lives and where possible, reduce their future needs for care and support. For example, the service collaborated with the Patient Participation Group (PPG) to organise a community health fair in June 2025. The event included representatives from local charities, health and social care organisations, the PPG, practice staff, local pharmacies, and a nearby supermarket. Attendees were offered health information and services, including screenings for BMI, blood pressure, and atrial fibrillation. The event also featured Tai Chi demonstrations and advice on physical activity. The PPG gathered feedback from attendees and, based on input from the 250 patients who attended, were planning further events.

The PPG also ran a weekly friendship café, open to all patients, which provided a welcoming space for social interaction and support.

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.

There was a comprehensive programme of clinical audit and quality improvement activity, tailored to the patient population and their health needs, to review the effectiveness and appropriateness of the care provided. 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 provider was achieving 84-86% childhood immunisation coverage for 4 out of the 5 routine childhood vaccinations. Coverage was 67% for children aged 5 who had received 2 doses of the immunisation for measles, mumps and rubella (MMR).

The practice had a system to identify and follow up with children overdue for immunisations. Monthly system searches identified children with outstanding vaccines, and initial contact was made via letters or text messages. Targeted engagement was provided for specific groups, such as the Romanian population, through direct contact by a Romanian-speaking nurse. Follow-up was carried out by practice nurses using calls, texts, emails, and letters to ensure multiple opportunities for engagement. All communications provided clear, informative guidance on vaccine benefits and safety. The practice also engaged with the local community, for example participating in a child health fair in July 2024, which resulted in several children receiving vaccinations or booking appointments.

Challenges, such as coding of decliners, transitory populations, and new arrivals with incomplete records, were managed through persistent recall and catch-up schedules. Ongoing monitoring was supported by weekly reports, ensuring timely follow-up.

The uptake rate for cervical screening was 73% among eligible women aged 50–64 years and 56% among eligible women aged 25–49 years, compared with the national target of 80%. The practice recognised the need to improve uptake and undertook quality improvement activity. Analysis of uptake by ethnic group identified lower participation among patients recorded as having Arabic and Hindi/Gujarati as their first language. Potential cultural and social barriers were identified, with provider communication considered a contributing factor.

The practice identified staff with Arabic and Gujarati language skills and allocated protected time for them to complete a cervical smear invitation learning module. Targeted telephone outreach was then undertaken with patients from these communities to support informed decision-making and encourage screening uptake. Calls were made by clinicians fluent in patients’ first languages, helping to address language, cultural, and informational barriers. This work was delivered over a 6 month period, with 1 hour per week dedicated to outreach.

As a result, uptake among Arabic-speaking patients increased from 38% to 43% in women aged 25–49 years and from 41% to 43% in women aged 50–64 years. Uptake among Hindi/Gujarati-speaking patients increased from 36% to 41% in women aged 25–49 years and from 43% to 45% in women aged 50–64 years. Overall cervical screening uptake also improved, increasing from 76% to 83% inwomen aged 50–64 years and from 56% to 61% in women aged 25–49 years. The practice planned for this work to continue as an ongoing quality improvement activity to achieve further improvements in uptake.

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.