Archived: Tollgate Health 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 not always involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care and treatment was not always based on latest evidence and good practice. We found patients had not always had health conditions clinically coded appropriately, and the summary of their medical problems were not always up to date. Staff worked inconsistently with agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff involved those important to people who took decisions in people’s best interests where they did not have capacity. There was not an effective system in place to demonstrate that persons provided care or treatment had the competence, skills, qualifications and experience to do so safely. There were limited assurances that staff had received clinical supervision and appraisals to be assured that they were competent to carry out their roles. There was not an effective programme of audits in place.At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.We identified breaches of regulation in relation to safe care and treatment, staffing and good governance.

This service scored 46 (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 were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

Whilst feedback from people using the service was positive, our assessment found assessment of needs did not meet the expected standard. During the remote clinical reviews, we found the provider did not have effective systems to identify people with previously undiagnosed conditions, for example diabetes in line with relevant best practice. Our searches found 6 service users with a potential missed diabetes diagnosis which did not follow National Institute for Health and Care Excellence (NICE) guidance. We reviewed 5 of these records and identified coding concerns with all 5 records. For example 1 patient had not been informed of their diabetes diagnosis, and therefore not referred for education and eye screening, putting them at an increased level of potential harm. There were referral pathways in place to make sure that patients’ needs were addressed, however urgent pathway monitoring processes were not effective. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. We were unable to gain assurance that reception staff were aware of the needs of the local community or how to signpost patient to local support groups. 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. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

Systems did not always ensure staff were up to date with evidence-based guidance and legislation. We found people with long-term conditions were not always offered appropriate monitoring following an acute exacerbation of asthma. Our clinical searches found 39 patients who had been prescribed 2 or more courses of rescue steroids for asthma in the previous 12 months. We reviewed 5 clinical records and found 3 patients were at risk of harm. All 3 patients had not been followed up within a week to check the response to treatment in an appropriate timescale following an acute exacerbation of asthma. This meant there was an increased risk of harm to these patients. We also identified concerns in relation to diabetes management. A search of potential missed diagnosis of diabetes identified 6 patients. We reviewed 5 patients and all 5 had identified coding issues. Two patients were at risk of harm, 1 of these patients was confirmed as having a missed diagnosis, and another patient had not been informed of their diagnosis, which could mean that the patients were not receiving the treatment they required. We shared our findings with the provider and did not receive full assurances that these people were followed up and no patient harm identified.

The service did not work well across teams and services to support people. They did not share their assessment of people’s needs when moving between different services.

We were not assured by leaders that they attended regular meetings with the primary care network (PCN). There was no evidence of the practice attending PCN meetings, including minutes from these meetings. PCNs are groups of GP practices that work together, and with other health and care providers, to deliver a wider range of services to the local population than might be possible within an individual practice. We asked for evidence of these meetings; this was not provided. We found on speaking with staff a lack of clear communication to support staff to appropriately assess, plan, and deliver people’s care, treatment, and support. Staff meetings were inconsistent and intermittent, for example safeguarding meetings. Minutes did not demonstrate effective identification and monitoring of actions. We were not assured the practice consistently worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services, including care homes and people in supported living accommodation.

The service did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. The service did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

We were not fully assured 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. We did not see evidence of a carers policy or data that identified the number of identified carers registered with the practice. This meant that patients did not have had access to appropriate health assessments, checks and support. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. During the onsite inspection we saw information leaflets displayed in the reception area to support and signpost people to services. Staff told us they referred people to the social prescriber to support improved outcomes for people.

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

The practice had not met all national targets for screening and immunisations. 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 of 80%. Early detection means less invasive interventions can take place at a precancerous stage, and the long-term adverse impact on women’s lives is reduced. We found no evidence to demonstrate the practice had a targeted programme in place to improve targets of cervical cancer screening. From the clinical notes we reviewed, we found an inconsistent approach to ensure that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. We found no evidence to demonstrate the practice had a programme of targeted quality improvement and staff told us they did not have protected time to undertake a programme of audits.

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.