Monkwearmouth 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

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. 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 remains the same.

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 did not always make sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

The practice had a system in place to ensure patients were routinely invited for their annual health checks. During these reviews, staff assessed individuals’ health, care, and wellbeing needs, and clinical staff used structured templates to support a comprehensive review of wider health and wellbeing. Although, we noted that when patients did not respond to review invitations after several requests, no additional steps were taken to encourage attendance or ensure compliance. Following our assessment the practice told us they had proactively contacted outstanding patients to put the required checks in place.

However, 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.

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. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

Child immunisations were all at 100% well above the 90% minimum vaccination rate recommended by the World Health Organisation (WHO).

Reception staff were aware of the needs of the local community. They 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.

The practice generally delivered care and treatment in line with legislation and evidence-based guidance, though some areas required improvement. For example, the clinical searches identified that most patients prescribed medication for the treatment or prevention of bone related conditions for 5 years or more had not a bone mineral density scan.

However, the service planned and delivered people’s care and treatment with them, including what was important and mattered to them.

The majority of feedback from people using the service was very positive, including the National GP Patient Survey where results were consistently above and, in some cases, well above the national average. From other feedback from NHS Friends and Family Test patients said they felt involved in the assessment of their needs and staff understood their individual and cultural needs.

The practice provided us with a range of audits they had undertaken to enhance care. These included annual cyclical audits, which help staff review and improve how certain treatments and health checks are managed, as well as ongoing audits focused on the safe monitoring of medicines that carry higher risks. Examples of these included audits of kidney functioning and diabetes to ensure they were being monitored and managed effectively.

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 spoke with the nursing home aligned to the practice, who reported consistently high levels of support from practice staff for their own team, patients, and families. The GP was routinely accompanied by the practice pharmacist and a community frailty nurse, ensuring a coordinated and integrated approach to patient care.

We saw examples of recent multi-disciplinary team meetings (MDT) where for example, safeguarding and palliative care were discussed.

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.

We found patients could access appointments with a variety of clinicians in a timely manner. This included primary care network staff, such as mental health, pharmacy services, health coaches and social prescribing.

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. They were also proud to be an Armed Forces accredited practice, to support serving and veteran patients.

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.

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 practice completed 37 reviews for patients with a learning disability in the last 12 months. For the past couple of years, an administrator has been responsible for coordinating appointments with patients or their carers. This approach has led to improved outcomes, as the administrator has developed an understanding of individual needs and the necessary adjustments to encourage attendance.

The 4 childhood immunisation indicators for the practice up to 31 March 2025, are currently at 100%. This exceeds the World Health Organization (WHO) target of 95% for routine childhood vaccinations. The practice operates a baby clinic every Thursday, and the nurse follows a structured process for booking appointments. Where appropriate, they also engage with parents, carers, or the health visitor to ensure effective communication and support.

The practice met national targets for screening and immunisations except for cervical screening test data for women aged 25 to 49 years and 50 to 64 years, with their respective intervals of 3.5 and 5.5 years, which fell slightly below the expected 80% target.

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.