Shakespeare Road PMS

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

At our previous assessment we rated the practice as requires improvement for the effective domain. We found that there was limited monitoring of the outcomes of care and treatment, and childhood immunisation and cancer screening data were below targets. At this assessment we found that the practice had improved monitoring of the outcomes of care and treatment. We saw that patients with asthma and diabetes had their needs met. We found that although childhood immunisation and cancer screening data were still below targets, we gained assurances that the practice had exhausted every possibility to improve the uptake of these.

We found that 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.

The practice had strong links to local community services and organisations that they were able to signpost patients to. This included services to deal with bereavement, carers, cost of living, mental health, debt and money, gambling and free food services.

This service scored 79 (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.

Feedback from people using the service was positive. 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. We found that a number of reception and clinical staff were multilingual and were therefore able to speak in patient’s first languages.

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 provider had effective systems to identify people with previously undiagnosed conditions. Through clinical searches on the practice’s clinical system we identified 7 patients with a potential missed diagnosis of diabetes. We reviewed 4 patient records and found that all patients had received the correct monitoring however, 2 patients required the correct codes being added to their clinical record to ensure appropriate follow up.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. We found that the practice had strong links with various different organisations within their community. This included, bereavement services, carers services, cost of living and mental health services as well as others available for patients.

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.

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. We identified 33 patients with asthma who had been prescribed 2 or more courses of rescue steroids. We reviewed 4 patient records and found that asthma reviews had been completed to a good quality, however, all 4 patients should have received a steroids emergency card. This was immediately addressed by the practice.

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.

We saw evidence that the practice had regular meetings which were used to share any changes across the practice.

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 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.

Staff had lead roles in areas including diabetes and asthma and worked closely with community teams to support patients. We found that the practice had built connections with several community services where they could signpost patients for extra support. A “Community Resources” booklet had been produced which listed multiple different services available for patients.

We received positive feedback from patients regarding how positive and supportive staff were. They said things such as “doctors make time to listen and explain what they are doing”.

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.

At our previous assessment we found that the practice did not meet national targets for screening and immunisations. At this assessment we found that the practice was still not meeting these targets. However, we saw that the practice had been putting in significant time and resources to continuously try and improve these figures. We felt assured that the practice was doing all it could to continually promote the importance of immunisations and screening.

The practice had a large number of Non-English speaking patients registered at the practice. For a lot of patients this was the first practice they had registered at. The practice identified that children newly registered at the practice did not always have clear records of their immunisation history which meant that they would have to start again, this affected the practice’s ability to reach national targets.

Due to a high number of patients with cultural beliefs and a transient patient population group the uptake for screening and immunisations were low. We saw evidence of how the practice ran regular reports for patients’ due immunisations and screening and contacted them to attempt to book appointments. The practice had also done engagement work with local Mosques, organised fun days, done education sessions in local schools and produced information leaflets in multiple different languages to attempt to improve uptake.

The provider had also involved Public Health England for assistance, this involved bringing in other agencies also. They were able to provide a Slovakian link worker who promoted the importance of immunisations and screening in their local community. Unfortunately, these external agencies were also unable to improve uptake.

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.

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.