Southfield Way 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

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure most people understood their care and treatment. Staff involved those important to the person when making decisions in their best interests, where the person lacked capacity. When decisions were made in people’s best interests when they lacked capacity, the practice took a multi-disciplinary approach but did not always ensure an assessment of mental capacity had been undertaken to inform decisions.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Feedback from people using the service was mainly positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual needs. This was also reflected in the national GP survey where 92% of practice respondents felt their needs were met during their last appointment. Reception staff told us they were a small practice and were aware of the needs of the local practice population and used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments.

At our last assessment we found some patients with long term conditions were not always adequately assessed to ensure they received the required monitoring in line with best practice guidance. At this assessment we found staff checked people’s health, care, and wellbeing needs during health reviews. However, the quality of some reviews required strengthening as the practice was not always using the standardised clinical templates designed to effectively support them with the management of people with long term conditions, particularly people with asthma and diabetes.

The practice had effective systems in place to identify people with previously undiagnosed conditions, for example we found no patients with missed diabetes or renal function. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber or care coordinator through their primary care network (PCN). The practice had 7 people on the register with a learning disability and advised 6 people had received an annual health check and 1 person had declined.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this mainly in line with legislation and current evidence-based good practice and standards. Systems were in place to act upon Medicines and Healthcare products Regulatory Agency (MHRA) alerts and other safety alerts. We signposted the practice to a historic MHRA alert relating to a specific medicine used to treat inflammatory conditions to ensure the day the medicine is to be taken is clearly stated in the directive and that it is linked to the patients’ medical condition. Following our feedback the provider took immediate action for the 11 people prescribed this medicine. We found the practice had improved their system to identify people with previously undiagnosed conditions in line with good practice. Our clinical searches found no patients with missed diagnosis of diabetes or significantly impaired renal function.

The service worked across teams and services to support people. They shared their assessment of people’s 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.

The practice worked with and held regular meetings with the social prescriber, care co-ordinator and external agencies including the district nursing team and local hospice to review patients nearing the end of their lives and discuss anticipated needs and preferences. Regular meetings were held between the lead GP and prescribers to discuss prescribing practices to ensure they align with best practice, offer opportunity for reflection and identify areas for improvement .

The practice was part of the Cannock Villages Primary Care Network (PCN), a group of practices that worked together to improve health outcomes for their patients. People had access to a range of services provided by the PCN including social prescribers, care co-ordinators, mental health practitioners, physio’s and pharmacists.

Since the last assessment the practice had formed a patient participation group (PPG) to help represent the voice of the patient population. The practice and PPG had worked together to improve patient experience.

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. 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. Patients had access to a social prescriber for emotional support and signposting to community groups and other agencies to improve their health and wellbeing. The practice nurse had provided a cervical cancer awareness event in the practice to raise awareness of and improve uptake and a further health education event was planned. A range of health promotion information material was available within the practice and on the provider website.

The practice monitored people’s care and treatment to improve it. The practice had partly met national targets for screening and immunisations. The practice was 5% below the national target of 80% for cervical cancer screening for persons eligible. A cervical cancer screening event had been held to promote uptake.

The practice had met or exceeded the World Health Organisation based target in 3 of the 5 childhood immunisation indicators. The provider told us they had contacted all parents for children on the list multiple times to get them to engage in the vaccination programme, but some had declined the vaccination and that although they encouraged uptake it was parents’ choice.

The practice had completed a range of audits for quality improvement. They acknowledged these required further development to include a continuous cycle, clear purpose, actions and outcomes to demonstrate improvement to patient care.

People we spoke with during our site visit told us they were provided with information to support them to make decisions about their care and treatment and their views and wishes were considered. Clinical staff spoken with demonstrated an understanding of consent and had access to a policy to support them. A representative of a local care home told us they had expressed concern regarding how the practice had documented consent in patient records in relation to vaccination. They considered there had been a lack of consultation and consideration of people’s rights and wishes and had raised this directly with the practice.

The practice had 149 people with a do not attempt cardiopulmonary resuscitation (DNACPR) decision in place. We sampled 5 patient records with these decisions in place. We saw evidence within records that discussions, decisions and preferences regarding advanced end of life had been recorded including patients, families and multi-disciplinary outcomes. However, 1 patient was considered not to have capacity, no record of a completed mental capacity assessment was available. Following our feedback, the provider confirmed that their policy had since been amended to reflect that a mental capacity assessment would be undertaken and that the form would be scanned onto the patient record. The 5 DNACRP decisions we sampled had been agreed within the previous 12 months. The provider told us a register of patients with these decisions was held and reviewed on an annual basis.