Monkwearmouth Health Centre

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination.

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

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 were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Care plans reflected physical, mental, emotional, and social needs of patients including those related to protected characteristics under the Equality Act. Our review of clinical records showed in most cases patients were supported to understand their condition and were involved in planning for their care needs. They were also involved in decisions about their care.

Feedback from staff was consistent, they said they worked well together as a team to provide good care for patients.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

We saw the practice worked in partnership with other services to meet the needs of its patient population. The practice had tailored its services to meet the diverse needs of its community. There were established mechanisms for engaging with the community healthcare provider.

We gathered feedback from the care home aligned to the practice. They reported that access to the practice was good, and the home’s nursing staff felt well supported by the team. The practice also collaborated effectively with the community frailty nurse during fortnightly visits, ensuring that both patient, family and staff needs were consistently met.

There was a process for identifying people with extra healthcare and communication needs. Alerts were added to their clinical records so that staff were immediately aware of how to assist them.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Information to promote the take up of screening and immunisation programmes was available in a range of languages. The practice had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard. Patients were informed as to how to access their care records.

The practice made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

We saw complaints were managed in line with the practice’s policy. The practice had a positive approach to receiving feedback and complaints. From the complaints we reviewed we saw the practice had responded to feedback appropriately, openly and in a non-defensive manner. Learning from complaints was evident and staff were able to identify changes made as a result of patient feedback. Staff demonstrated an understanding of their Duty of Candour and the importance of being open, honest, and transparent when things go wrong

The practice routinely asked patients to complete Friends and Family Test (FFT) feedback forms and reviewed the feedback for any trends or themes. Data from the FFT showed that for the month of November, 38 patients had responded, and the practice had received 100% positive comments. This was similar for the 2 previous months of October and September of 99% and 100% positive comments.

Results from the National GP Patient Survey showed the practice performed above the national average, achieving 93% of respondents who stated that during their last appointment, the healthcare professional was very good or fairly good at listening to them, (the national average was 87%).

People could expect their care, treatment and support to be accessible, timely and in line with best practice, quality standards and legal requirements, including those on equality and human rights. This included making reasonable adjustments for disabled people, addressing communication barriers and having accessible premises. For example, to encourage attendance for learning disability annual reviews reasonable adjustments were made such as inviting some patients by phone and having an initial call with the nurse first before the appointment.

Leaders worked to provide routine appointments within 2-3 days for patients and there were emergency appointments available on a daily basis. Results from the National GP Patient Survey showed the practice performed significantly better than national averages in several areas concerning access. For example, 90% of patients responded positively to the overall experience of contacting their GP practice, compared with the national average 70%.

Services were designed to make them accessible and timely for people who were most likely to have difficulty accessing care. When there were barriers, they were removed. Patients could access appointments online, over the phone and in person. The practice population consisted of over 30% elderly patients and so the practice decided against the implementation of an ICB total triage system as it was deemed unsuitable for the current patient group.

Leaders managed staff working hours and staff days off to ensure peak telephone call times were well staffed. Additional practice staff were also available on call when required. Results from the National GP patient survey also highlighted that patients could easily access the practice, 96% of patients found it easy to get through to the GP practice by phone (national average 53%).

The provider used people’s feedback and other evidence to actively seek to improve access for people more likely to experience barriers or delays in accessing their care. In response to data from the National GP Patient Survey and feedback from the local community, the provider implemented changes to improve service access. For instance, they analysed the surge in prescription-related calls at 10 a.m., identified patients who were not using the NHS app, and promoted its adoption. At the time of the assessment, this initiative included a prominent display in the waiting area encouraging patients to use the NHS App. Staff had been trained to use the NHS App and were able to show patients in the practice if they were struggling to use it.

The premises was wheelchair accessible, and all patients were seen on the ground floor. The practice had a hearing loop.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Feedback provided by people using the service, both to the provider as well as to CQC, was positive. Staff treated people equally and without discrimination. Leaders proactively sought ways to address any barriers to improving people’s experience and worked with local organisations, including within the voluntary sector, to address any local health inequalities. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and Travellers. Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to the internet

The practice was responsive to the needs of older patients and offered home visits and urgent appointments for those with enhanced needs and complex medical issues.

Systems and processes were in place to assist in identifying patients who may need extra support. This included alerts on patients records to show what support they needed with communication such as interpreters. We saw staff liaised regularly with community services to discuss and manage the needs of patients with complex medical issues.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Our records review showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. This information was shared with other services when necessary.

The practice fully engaged in regular, well attended multi-disciplinary team meetings to assess and support patients in reaching decisions about their end-of-life care. This identified that patients’ views had been sought and respected. We were assured that safeguards were in place to ensure that decisions were made which were in the person’s best interest. When patients did not have mental capacity to make their own decisions regarding end-of-life care, family members and carers were involved in decision making.