Pathfields Medical Group

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 assessed all quality statements in the effective key question. Our rating for this key question remains good. Staff regularly reviewed people’s care and worked with other services to achieve this. 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 all agencies involved in people’s care for the best outcomes and smooth transitions when moving between services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people when making decisions in people’s best interests if they had been assessed as not having mental capacity.

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. Care and treatment was regularly reviewed and updated. People felt involved in any assessment of their needs and felt confident staff understood their individual needs. Digital flags within care records highlighted any specific individual needs, such as the requirement for longer appointments or for a translator to be present. 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. There were appropriate referral pathways to make sure people’s needs were addressed. People presenting with symptoms which could indicate serious illness were followed up in a timely and appropriate way. Staff were aware of the needs of the local community.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. Systems ensured staff were up to date with evidence-based guidance and legislation. Clinical staff were invited to attend regular evening education sessions to learn and share new systems and processes. The service had developed an extensive set of ‘process maps’, containing guidance for staff to follow to ensure a consistent approach to care. Clinical records we saw demonstrated care was provided in line with current guidance. Our clinical searches identified 243 patients prescribed aldosterone antagonists (a medicine to treat high blood pressure and heart failure) and found 13 of these patients had not received monitoring in line with guidance. We reviewed 5 of these patient records and found concerns with 4 of these patients. We saw evidence demonstrating the service had taken steps to prescribe safely by reducing prescriptions to 7 days to encourage people to attend for monitoring and saw emails from the local heart consultant confirming prescribing needed to continue. The service also immediately reviewed the associated process map to include guidance on prescribing for people that had not attended repeat invites for monitoring.

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 or received from other services. Staff told us they liked the team-working environment and enjoyed working at the service. Feedback from partners was positive with how the services worked together to support vulnerable members of the community. Partners told us staff were easily contactable and listened to their concerns about the people they supported.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff told us they discussed changes to care or treatment with people and their carers. 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 people’s health, including those in the last 12 months of their lives, people at risk of developing a long-term condition and those with caring responsibilities. The service website contained information and links to other sources of information to support people to make healthier choices and support their lifestyles. People shared positive feedback with us on the efficiency of the flu vaccination clinics the service delivered: “The service was quick and professional and ensured that I was protected for the winter”.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves where possible. The service met national targets for childhood immunisations. For some people who did not speak English as a first language, they were sent messages in their first language to invite their child in for immunisation. We reviewed clinical notes and found people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. Verified data for cervical screening available at the time of this assessment was from June 2023 and showed the service was not meeting the national uptake target of 80%. Unverified data shared by the service showed they were working towards achieving an 80% uptake of cervical screening this year. Patients with long-term conditions were offered an effective annual review to check their health and medicines needs were being met in line with guidance. Our clinical searches identified 778 people diagnosed with hypothyroidism (a condition where the thyroid does not produce enough hormones). We identified 8 people that had not received the appropriate monitoring in the last 18 months and reviewed their patient records. We saw evidence the service had attempted to contact these individuals to invite them in and some had been reduced to 7-day prescriptions to encourage them to attend for monitoring.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. Policies, protocols, and guidance were followed to support people to consent to care and treatment. Staff had completed Mental Capacity Act training. They understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were made in line with relevant legislation.