Morland Road 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 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. For example, results from the GP Patient survey showed that 92%of patients said they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment.

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.

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. Our review of medical records confirmed this, although through our review of patients with diabetes, we identified, improvements that could have been made. We discussed this with the GPs, and they explained that they were fully aware of the situation. They felt that they had a higher than average number of diabetic patients and they were working towards improving things. This includes setting up a specific weekly clinic with the pharmacist to see patients with a very raised HbA1c and working closely with a diabetic consultant.

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 social prescribers worked closely with staff in the practice, visiting twice a week.

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. GPs were signed up to medical journals and received weekly newsletters with updates. The GPs told us that as they were a small team they spoke regularly and discussed each other’s cases to ensure consistency and share knowledge. Clinical meetings were used to discuss new guidelines. The GPs gave us examples of a recent guideline relating to gynaecology they discussed. 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 manager told us that all changes were shared with staff via email. Important updates or changes were printed, and staff had to sign them to confirm they had seen it. This was to ensure people were kept up to date with the latest information. Staff we spoke with confirmed this process.

The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. For example, when the community team or out of hours services sent information it was sent to the GP and then the GP would assign it to a member of the team to action. Information was also shared via the monthly primary care network (PCN) meetings.

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. For example, patients at risk of developing diabetes were referred to “live well” programmes for dietary and exercise support.

Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. Patients were referred to various initiatives including weight loss and smoking cessation services. Patients were referred to the social prescribers actively for assistance with social and economic problems.

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 had not met any of the national targets for screening and immunisations, although most targets were just below. For example, the percentage of children aged 1 who have completed a primary course of immunisation for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus influenza type b (Hib), Hepatitis B (Hep B) was 87.2%, just below the target of 90%. And the number of women in this age group who have had an adequate screening test within the last 5.5 years as a percentage of the eligible population aged 50 to 64 years old was 78.5% just below the target of 80%. Despite the rates, the practice was doing numerous things to try and reach patients. This included having a system in place where parents were contacted multiple times if they did not respond to immunisation appointments, including sending the text message in their own language if they felt this was contributing to the non-response. There was a dedicated member of staff whose role was to encourage the uptake of 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 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. GPs told us they reviewed DNACPR forms when they visited their patients who were in a local nursing home.