Northgate Medical Centre

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 all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity.

This service scored 71 (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.

People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight 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. The practice sent learning disability invitations with clearer and simpler text to support patients' understanding of the purpose of a review. The provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. We reviewed the practice’s Accessible Information Standard (AIS) policy.

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. We found that patients mostly received appropriate monitoring at the required intervals, however there were areas for improvement we identified and raised with the provider to take forward and action.

Our remote clinical search identified the practice had 484 patients with hypothyroidism. We sampled 5 patient records and found all 5 patients required further monitoring.

Our remote clinical search identified the practice had 1414 patients with asthma. We found 44 patients had required 2 or more courses of rescue steroids in the last 12 months. We reviewed 5 patients and found patients had received the appropriate treatments and monitoring, however, 3 out of the 5 patients required a steroid card, 3 required asthma reviews, and 1 patient required further monitoring. The practice took immediate action to address this.

Our remote clinical search identified there were 74 patients with Chronic Kidney Disease Stages 4 or 5. We found the patients had the required blood monitoring to assess their kidney function in the previous 9 months.

Our remote clinical search identified the practice had 816 patients with diabetes. We sampled the records of 5 patients with diabetes who’s latest HbA1c (blood glucose) level was consistently high. We found 2 patients required further monitoring and review. The practice took action to address this immediately.

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 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.

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.

The service offered NHS Health checks to eligible patients between the aged 40-74. Awareness days were available to patients to enable them to access services such as breast screening, prostate cancer and cholesterol checks. The practice also supported patients who were going through cancer journeys, organising mental health events as well as stop smoking and weight management led sessions.

There were flags on patients records who were vulnerable and required ongoing monitoring and recalls in place to review patients and educate them to manage their health needs. The practice website detailed information and links to health promotion, health conditions and common health questions.

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. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The latest GP Patient Survey, showed that 96% of respondents felt their needs had been met during their last general practice appointment, which was above the local average and above the national average of 90%.

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.

The practice met national targets for screening and immunisations. From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

Cervical screening uptake at the practice was 78% among patients aged 24–49 and 50–64, slightly below the national target of 80%. Breast and bowel screening rates were higher than national averages. National data indicated that all five indicators for childhood immunisations were above the World Health Organisation’s minimum threshold of 90%.

In collaboration with the PCN, the practice was actively working to reduce barriers to patients receiving care. For example, it supported the planning of locations for mobile breast screening units to improve accessibility. The practice also used social prescribers to engage with patients who were hard to reach and delivered health promotion initiatives, including dietitian-led group sessions, to support patients’ wellbeing.

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

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.