South View Partnership

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• 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 with advice and support. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff regularly reviewed people’s care and worked with other services to achieve this. Staff made sure people understood their care and treatment to enable them to give informed consent.

The service demonstrated a strong commitment to improving the health of the local population. We found that the service had highly effective systems for assessing the needs of patients and had achieved higher than average rates in terms of uptake for annual health checks. These systems supported early intervention, improving outcomes for patients.

This service scored 83 (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 the assessment of their needs and felt confident that staff understood their individual and cultural needs. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or a translator. 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 wider health and wellbeing. Staff identified opportunities to refer people to social prescribers (a service that connects people to activities, groups, and services in their community) to help improve health and wellbeing.

The provider had especially robust systems to identify people with previously undiagnosed conditions. For example, the service used available tools to screen for conditions such as diabetes and was able to proactively identify patients with the condition and to assess their needs and begin treatment as early as possible.

We found that the service had highly effective systems for assessing the needs of patients with learning disabilities. This resulted in the service achieving a 98% completion rate for annual health checks for patients with learning disabilities. This was the highest percentage achieved within the local borough. The service also contributed to the borough’s Learning Disability Strategy, demonstrating a commitment to improving care for this population group across the wider area.

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. The service had appointed designated staff members to take the lead on ensuring patients with long term conditions were reviewed in line with national guidance. The service actively conducted searches to identify patients at risk of developing long term conditions, including diabetes. A service for patients to have their blood pressure checked at home was also available.

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. For example, the service participated in multi-disciplinary meetings across the borough and within the primary care network. This includedreviews for housebound patients, stroke rehabilitation planning, and social prescribing-led follow-up. Staff completed training which targeted specific areas of need, includingchronic kidney disease and lipid optimisation.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service demonstrated a strong commitment to improving the health of the local population. This included by participating in a wide range of projects that focused on the needs of patients, and which used data to measure the impact. Projects included educational evenings in collaboration with secondary care providers aimed at increasing the uptake of cancer screening amongst groups with lower engagement levels. The service also adopted a screening programme for gambling-related harm.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. The PPG ran initiatives encouraging patients to become more active. This included walking groups and helping to maintain the practice garden.

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.

In particular, the service demonstrated a strong commitment to improving outcomes for patients by introducing measures to support early intervention. This included the introduction of a pathway to diagnose urinary tract infections onsite to allow for early diagnosis and treatment. The effectiveness of this pathway was monitored with regular audits. A GP and a nurse at the service had also received specialist training to fit pessaries for uro-gynaecology issues. This resulted in earlier intervention and improved outcomes for patients requiring this treatment.The service performed above local averages in respect of cancer referrals. This included the effective utilisation of rapid diagnostic centre pathways (136% achievement rate).

We reviewed the service’s performance data for cervical screening and immunisations, and found they were meeting national targets for all but two indicators. Data showed that 68% of eligible patients had received cervical cancer screening (target 80%) and 80% of children under 2 had received a pneumococcal conjugate booster (target 95%). We found that the service took steps to improve the uptake of cervical screening by producing an information video for patients, offering Saturday appointments for patient unable to attend screening during the week. The service also held a ‘cancer awareness evening’ and offered information leaflets in a variety of languages. The service was aware that some patients underwent screening in their home countries and took steps to obtain and record the results. The service reviewed monthly lists of children due to receive immunisations and contacted parents to encourage them to make appointments.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.
Staff we spoke to demonstrated that they understood and applied legislation relating to consent. Capacity and consent were clearly recorded. We found that do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.