Scott Road Medical Centre

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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 advice and support, and that 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 has changed to requires improvement.

This service was in breach of legal relation in relation to safe care and treatment.

This service scored 58 (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 did not always make sure people’s care and treatment was effective because they did not always check and discuss people’s health needs with them.

A CQC GP SpA completed a series of clinical searches to review the records of patients with long-term conditions and ensure the required monitoring was taking place. People’s care and treatment was not always reviewed and updated when it should be. Further details can be found under the key question of safe in ‘Medicines optimisation’.

Our clinical searches identified 44 patients with a potential missed diagnosis of stages 3 to 5 chronic kidney disease (CKD) who required review. Following the assessment, the provider told us they were following NICE guidance for the diagnosis and management of CKD. The provider told us one patient had not been coded appropriately and that action had been taken to address this. Our search also identified 31 patients with stage 4 or 5 CKD. Of those patients, 6 had not had the required (urea and electrolyte) monitoring in the last 9 months. We looked in detail at 1 patient record and found they were well managed by secondary care.

We identified 1516 patients on the asthma register. Of those patients, 54 had been prescribed 2 or more courses of rescue steroids in the last 12 months. We looked at 3 of these patient records in detail and found asthma was generally managed well by the service with patients having an up-to-date asthma review. However, we identified 1 of the 3 patients was overdue a medication review.

We identified 417 patients with hypothyroidism. Of those patients, 2 had not had the required monitoring in the last 18 months. When we looked at the records for those 2 patients in detail, we saw evidence the service had taken appropriate action to try and complete these reviews. However, we did identify 1 patient was overdue a medication review.

We did not have any concerns over the identification of patients with diabetes. We found evidence of satisfactory monitoring of this condition by the service. However, we did identify 1 patient was overdue a medication review.

We received mixed feedback from providers of residential / nursing homes whose residents received a service from Scott Road Medical Centre. This included concern over the assessment of residents’ needs often being made by the service over the telephone.

Patients provided mostly positive feedback about the service. They felt involved in any assessment of their needs.

Staff checked people’s care and wellbeing needs during health reviews. Staff could refer people with social needs to a Social Prescribing Link Worker. For example, those patients experiencing isolation or housing difficulties.

The service had a process in place to identify people with caring responsibilities and to support those patients wherever possible.

The service did not always plan and deliver evidence-based care and treatment to patients. They did not always follow legislation and current evidence-based good service and standards.

Findings from our clinical searches indicated not all patients received care in line with national guidance. Examples of these findings have been reported under the key question of safe in ‘Medicines optimisation’ and under the key question of effective in ‘Assessing needs’.

The service did not have a system in place to ensure staff were always up-to-date with evidence-based guidance and legislation.

Staff did not always deliver care to patients in line with evidence-based guidance provided by NICE. We saw evidence where this had led to incidents which negatively impacted the safe care and treatment of patients. For example, a patient diagnosed with asthma was not given appropriate information about their condition and the use of an inhaler.

During our assessment, feedback was given to the service concerning patients identified from the clinical searches so that those patients’ clinical records could be reviewed and actioned appropriately.

The service worked well across teams and services to support people. They made sure patients only needed to tell their story once by sharing their assessment of needs when people moved between different services.

We received positive feedback from patients about the service working well with other services. The service worked with others to ensure continuity of care, including where clinical tasks were delegated to other services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment and support. The service utilised a real-time digital care management system that ensured accurate, up-to-date care plans across all NHS services.

Leaders and staff worked with the PCN to meet the needs of the patient population. Regular multidisciplinary meetings took place so that when patients received care from a range of different staff, teams or services, this was co-ordinated.

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 patients in the last 12 months of their lives, those at risk of developing a long-term condition and those with caring responsibilities.

The service provided a ‘carer pack’ to patients identified as having caring responsibilities. Carers were invited by the service to have a flu vaccination every year, and they were offered flexibility around appointments to fit in with their caring responsibilities.

Staff utilised appointments to discuss and encourage patients to make positive lifestyle choices where appropriate.

The service supported national priorities and initiatives to improve population health. For example, by encouraging patients to ‘stop smoking’, and registering and promoting Scott Road Medical Centre as a ‘parkrun practice’.

There was a wide range of support and advice information available for patients on the practice website and within the premises.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure outcomes were positive and consistent, or that they met both clinical expectations and the expectations of patients themselves.

Our clinical searches identified the service did not always monitor patients to ensure positive health outcomes from the medicines they were prescribed. Please refer to the examples provided under the key question of safe in ‘Medicines optimisation’ and under the key question of effective in ‘Assessing needs’.

The service carried out clinical audits to try to improve outcomes for patients. However, the service did not have an effective system in place to maintain oversight and ensure improvement across audit cycles.

Based on published data from 30 June 2024, the percentage of patients aged 25 to 49 years who were eligible for cervical screening and who were screened adequately by the service was 76.9%. The percentage of eligible patients aged 50 to 64 years who were screened adequately by the service was 77.7%. Unverified data at the time of our assessment provided to us by the service showed they had since achieved above the 80% target. At the time of our assessment, the service was undertaking a trial to contact eligible patients who had not yet had cervical screening to try and encourage better engagement and overcome potential barriers felt by patients to having the screening done.

The most recent published data (1 April 2023 to 31 March 2024) showed the service met the World Health Organisation (WHO) 95% target for 3 out of 5 childhood immunisations. The service met the 90% uptake target for all 5 childhood immunisations.

Patients with a learning disability were offered an annual health check.

Unverified data provided by the service showed that 330 NHS health checks had been completed out of 446 eligible patients in the last 12 months.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff had completed training in the Mental Capacity Act. We found ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) decisions were appropriate and made in line with relevant legislation. We saw evidence to confirm appropriate discussions had been held with patients (and/or their carer) about DNACPR decisions. The mental capacity of patients was considered. Multidisciplinary approaches to decision making were made where necessary.

The service had swapped from a DNACPR form to a ‘Recommended Summary Plan for Emergency Care and Treatment’ (ReSPECT) form. They were in the process of ensuring relevant information was expanded on for patients using the new form type, and that all information was recorded on their system appropriately.

The service had recently completed an audit relating to consent for joint injections. The audit concluded informed consent for joint injections was consistently obtained and was documented appropriately.