Southway 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 assessed all quality statements in the effective key question. At our last assessment we rated this key question as requires improvement. This was due to the provider having delayed patient care reviews, lack of staff training or awareness of people with learning disability and autism, and staff being unable to attend meetings. At this assessment we rated the key question as good. Regular reviews were undertaken of people’s care. Assessments took account of people’s communication preferences, personal and health needs. Staff worked with other agencies involved in people’s care for the best outcomes and smooth transitions when moving between services. Care was based on the latest evidence and good practice. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people when making decisions on best interests if they had been assessed as not having mental capacity.

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. Feedback from people using the service was positive. Our remote clinical searches found people with respiratory diseases such as asthma or COPD (a condition which causes breathing difficulties) all received a follow up phone call and had reviews with new care plans put into place when needed.

Reception staff used digital flags within the care records system to highlight any specific individual needs. Staff used these alerts and flags on patient records to ensure patients communication, disabilities and any impairment needs were highlighted for staff to tailor patient care. Staff were aware of the needs of the local community. This could include a requirement for longer appointments or for a translator to be present.

Assessments of people’s physical health, wellbeing and communication needs were in place. Care plans were clear and up to date and showed appropriate details of health needs and what support was needed. 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 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. There were appropriate referral pathways to make sure people’s needs were addressed. People presenting with symptoms which could indicate a serious illness were followed up in a timely and appropriate way. We found that all staff were compliant with recommended training on Learning Disability and Autism.

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. There were systems to ensure staff were up to date with evidence-based guidance and legislation. Staff told us they were provided opportunities to keep up to date with current guidelines and changes to evidence-based care and treatment. For example, we saw evidence of this having been discussed in clinical and all staff meetings. Clinical records we saw demonstrated care was provided in line with current guidance.

Our remote clinical searches showed patients care and treatment was monitored in line with current legislation, standards and evidence-based guidance including from the National Institute for Health and Care Excellence (NICE), referred to as NICE guidance. For example, we reviewed 5 patients with diabetes. Our remote clinical searches showed there was oversight of long-term conditions management to ensure evidence-based care and treatment was given to patients within appropriate time-frames. All records reviewed had appropriate management of symptoms and patient’s received medicinesadjustments according to recent test results.

The practice worked effectively 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 practice had systems which enabled them to share information about patients with other services. For example, paramedics were able to access their patient records to ensure continuity of care.

Staff told us they liked the team-working environment and enjoyed working at the practice. Representatives of the Patient Participation Group (PPG) told us they felt positive about working with the practice and were confident in their concerns being addressed. Staff considered leaders were team-focused and offered a supportive working environment and they had an open door policy. Staff said there was effective information sharing and they were kept up to date on changes and patient outcomes. Since our previous inspection, overall communication had improved and this was demonstrated by lessons learned being shared and discussed in meetings.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. The practice supported people to live healthier lives and where possible, to reduce their future needs for care and support.

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 were supported appropriately. Staff encouraged uptake of national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. The practice website contained information and links to other sources of information to support people to make healthier choices and support their lifestyles.

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. Staff encouraged patients to attend for screening and childhood immunisations. Patients who did not attend were followed up. Audits to monitor patient outcomes were being utilised and the information used to make improvements.

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. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. These were regularly reviewed by the practice partner to make sure the information was correct. The DNACPR forms were completed in full and securely saved to the patients care records and clearly evidenced peoples, or their representatives involvement. People were involved in care planning and offered support to meet their needs. Staff were able to demonstrate how they would assess a person’s capacity to make a decision and had received training on the Mental Capacity Act (MCA) 2005. Policies were in line with best practice guidance relating to consent and MCA including details of best interest decision making.

Staff we spoke with understood Gillick competency. There was a process to ensure young adults had control over their own privacy and the amount of parental involvement in managing their care and support.