Swallowfield Medical Practice

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

The service provided effective care and treatment based on current evidence-based guidance and best practice. Staff assessed patients’ needs appropriately and involved them in decisions about their care, ensuring care plans were personalised and regularly reviewed. The practice worked collaboratively with a range of professionals to support continuity of care and improve outcomes for patients.

Staff supported patients to manage their health and promoted healthy lifestyles, with strong performance in national targets such as screening and immunisations. Systems were in place to monitor and improve outcomes, and patients received care that met their needs. Consent was obtained appropriately, and staff understood and applied relevant legal frameworks.

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 and cultural needs. 97%of the respondents felt their needs were met during their last general practice appointment. This was higher compared to the local average of 91% and national average of 90%.

The provider was aware of the needs of the local community. 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.

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.

Clinicians focused on proactively managing moderately frail patients to improve outcomes and reduce future healthcare demand.

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.

Our review of the clinical record system indicated that patients received care, treatment and support that was evidence-based and in line with good practice standards. The management of patients living with long term conditions was effective and our searches did not identify any gaps in the monitoring of patients.

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.

Staff reported that communication within the practice was sometimes disjointed. They felt the communication could be improved, particularly around sharing learning from significant events and complaints.

The provider held a range of internal and external meetings to share information and collaborate across teams and services, ensuring better support for patients.

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.

Patients with a learning disability or diagnosed with dementia were invited for an annual review with a GP. Personal information such as routines, communication needs and capacity was considered along with their nutrition, mobility, and medication needs

The practice’s website included helpful links to external resources covering areas, for instance weight management, women’s health, stop smoking services, sleep support, and self-care, aimed at supporting patients in managing their health and wellbeing.

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.

The practice conducted audits to review safe prescribing of medicine. For example, a recent audit on an anti-seizure medicine identified gaps in secondary care review and documentation. Patients without appropriate review were referred to specialist services and affected patients were provided with updated safety information. We noted practice systems and medication review policy were updated to ensure compliance with guidance.

The practice met national targets for screening and immunisations. From the clinical notes we reviewed, we found people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The practice demonstrated strong performance in childhood immunisations, achieving a 95% uptake rate.

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.

We looked at a sample of DNACPR decisions in patient records. Appropriately completed documents were available and had been shared with other relevant services and alerts had been added to the patient record system.

Care home residents had a specific care home plan created. Each care plan was individual to the patient and was tailored to their circumstances.