St Martin's Gate Surgery

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 assessment, 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 practice made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. The practice had systems and processes in place to identify patients’ needs and preferences during the registration process. For example, they used registration forms to identify carers. The practice used digital flags within the care records system to highlight any specific individual needs such as the requirement for longer appointments.

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. Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. For example, they held regular multi-disciplinary education sessions. The remote clinical searches we undertook of the practice’s clinical records system showed the monitoring of people with long-term conditions were followed in line with National Institute for Health and Care Excellence (NICE) recommendations. For example, we identified 140 patients with diabetes whose last blood glucose reading was over 75. We reviewed a random sample of 5 records and found that all patients had an up-to-date medicine review and blood glucose test.

The practice 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. We saw that communication between staff was open and frequent, for example in the daily huddle meeting. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. We saw evidence of staff from the PCN attending practice meetings to discuss services that they could offer.

The practice 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. The practice had a GP who had a specialist interest in women’s health and had completed additional training in hormone replacement therapy (HRT) to support women who were going through menopause. The practice had introduced a blood pressure machine in the waiting room to allow patients to do their own blood pressure readings. This also meant patients did not need to book an appointment to get their blood pressure readings. Staff focused 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 tackling obesity.

The practice 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. The practice met majority of the national targets for screening and immunisations. 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 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. Staff were able to explain how they involved people to obtain consent to specific decisions. For example, the nurse obtained and recorded verbal consent from the parent or guardian in relation to childhood immunisations.