Heswall and Pensby Group 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

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 used clinical searches, recall systems and population health information to identify people who required review, monitoring or additional support. Staff used this information to help ensure people received appropriate assessment and care in a timely way.

The provider used information about people's health and wellbeing to identify those who may be at greater risk of poor health and prioritise them for additional support or intervention. Staff also considered people's wider health and social needs and used other services, including social prescribing, where appropriate. For example, the service used a programme focused on heart, kidney and other long-term health conditions to identify people at increased risk of poor health and support earlier assessment and intervention.

Staff used information gathered through assessments, reviews and investigations to make decisions about people's care and treatment. Urgent concerns were identified and prioritised according to clinical need.

Structured monitoring and review processes were in place for people with long-term conditions and those requiring ongoing monitoring. Reviews considered people's changing needs, preferences and future care requirements where appropriate.

The service had systems in place to ensure care and treatment was delivered in line with current evidence, guidance and professional standards. Staff we spoke with described opportunities to discuss changes in guidance through clinical meetings, training and professional development activities.

The provider used clinical audit activity to review practice, monitor compliance with guidance and identify opportunities for improvement. Audit findings were used to improve monitoring arrangements, prescribing practices and patient review processes. Repeat audits were undertaken to assess whether changes had been effective.

Structured medication reviews supported safe and evidence-based prescribing decisions. Reviews considered people's health conditions, treatment burden and ongoing need for medicines, helping to ensure treatment remained appropriate for their needs. For example, reviews considered whether medicines remained beneficial and whether treatment should be reduced or stopped where the risks outweighed the potential benefits.

The provider reviewed and acted on medicines safety alerts and used antimicrobial stewardship activities to support safe prescribing. Clinical supervision and audit processes provided assurance regarding the quality of assessments, prescribing decisions and patient care.

The service used a multidisciplinary approach to deliver care and ensure people were supported by the most appropriate professional. Staff worked collaboratively across clinical and non-clinical teams to meet people's needs and provide coordinated care.

The service had established arrangements to support communication and joint working between different professionals. This included collaborative working around long-term conditions, medicines management, safeguarding and care planning.

Staff worked effectively with other health and care services to support continuity of care. Referral pathways were monitored and patients were followed up where required to reduce the risk of people being lost within care pathways.

The provider also worked with community services, social prescribing teams and other partner organisations to support people whose needs extended beyond healthcare alone.

Feedback received indicated that people with complex needs and their carers experienced coordinated care from multiple professionals and services.

The service supported people to live healthier lives through prevention, health promotion and ongoing support to manage their health and wellbeing. Staff carried out regular reviews for people with long-term health conditions and used these opportunities to provide advice, monitoring and support.

The provider promoted preventative healthcare and supported people to understand and manage risks to their health. NHS health checks, blood pressure monitoring and cardiovascular risk assessments were used to identify people who may benefit from further review or support.

Staff supported people to access health promotion activities and preventative services available through the provider, the Primary Care Network (PCN) and partner organisations. Social Prescribers also supported people whose wider social or wellbeing needs may affect their health outcomes.

For example, the provider promoted menopause-related events and used these opportunities to encourage eligible patients to participate in cervical screening and access additional health information and support.

The service routinely monitored people's care and treatment to support positive outcomes. Leaders reviewed performance information, clinical data and population health information to identify areas requiring improvement and monitor the effectiveness of care provided.

Structured monitoring and recall systems were used to support long-term condition management, medicines monitoring, screening programmes and preventative healthcare. Staff used this information to identify people who required review, additional support or follow-up.

The provider used clinical audit activity to review outcomes and drive improvement. Audit findings were used to strengthen monitoring arrangements, improve clinical pathways and identify people who may benefit from further intervention. Re-audit activity was undertaken to assess whether changes had been effective and resulted in measurable improvement.

Screening and immunisation performance was monitored and reviewed through governance processes. Cervical screening uptake exceeded the national target of 80%, with uptake of 94% for women aged 25 to 49 and 86% for women aged 50 to 64. Childhood immunisation uptake remained below the national target, with uptake ranging from 73% to 88% across the cohorts reviewed. However, leaders had recognised this and implemented targeted activity, including support from Social Prescribers, to improve engagement and uptake.

Staff understood the requirements of consent and the principles of the Mental Capacity Act. People were supported to make informed decisions about their care and treatment through discussions about treatment options, risks, benefits and alternative approaches.

Staff understood that capacity should be assessed in relation to the specific decision being made and recognised that people with cognitive impairment may still have capacity to make decisions about their care. Where appropriate, capacity assessments and best-interest decision making were considered.

People were supported to make their own decisions, and staff understood the importance of respecting individual choice. Consent was sought before sharing personal information and staff checked consent arrangements before disclosing information to third parties.

Decisions about whether cardiopulmonary resuscitation should be attempted were reviewed regularly and reflected people's wishes and changing circumstances.