The Acocks Green 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

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 requires improvement due to not completing audits and assessing risks. At this assessment, the rating has changed to good.

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.

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.

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

As part of our assessment, remote clinical searches were conducted by a GP Specialist Advisor (SpA). Our GP SpA found that most people had their needs assessed within the correct timeframes. For example, all people with chronic kidney disease had been reviewed within the last 9 months.

A person with diabetes had a blood sugar level that was higher than the recommended range; this had not been flagged on the system to prompt a diabetic foot check, which may place the person at increased risk of complications. The service took action to follow up the person and address the oversight, and we saw all of the other people in this category had received appropriate checks.

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. For example, we saw that people who were prescribed strong painkillers had regular reviews to ensure that the medicines were used safely.

Clinical audits and reviews were taking place within the GP practice. Clinical audits identified areas for improvement and allowed the management team to address concerns. An example was how managers agreed triaging be done by phone or in person for those without internet access, following patient feedback. This was an improvement since the last inspection ensuring people without internet access could still be triaged promptly.

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 told us they had access to the information they needed to assess, plan and deliver people’s care and treatment. They explained that referral pathways were clear, and they received the necessary information and results back in a timely manner to support ongoing care.

There were systems and processes in place to enable information to be shared between the practice and services to ensure continuity of care. Regular meetings were held with multi-disciplinary teams such as Multi Agency Risk Assessment Conference (MARAC) to ensure care was coordinated effectively. Meetings to discuss complex people, those receiving palliative care and requiring further support were held and recorded with outcomes.

The practice was part of a provider network and could access a range of other services for advice, support and guidance

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 people’s health, including those in the last 12 months of their lives, people at risk of developing long-term conditions and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

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

The service did not meet national or local targets for screening and immunisations. The provider reported challenges following up on immunisations and cervical cancer screening due to many people living in temporary housing. Despite repeated letters, calls, and texts, some people moved away or declined care. The provider was developing an action plan to improve. However, at the time of the inspection they remained below minimum targets.

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

We found capacity and consent were clearly recorded in people’s records and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were appropriate and made in line with relevant legislation. Appropriate discussions had been held with people (and/or their carers) about DNACPR decisions, and the mental capacity of people was considered. ReSPECT forms (Recommended Summary Plan for Emergency Care and Treatment) were also completed appropriately.

Where appropriate, people were offered a chaperone for care and treatment. During our site visit we saw chaperone posters were displayed to inform people of this service. Staff providing this service had completed relevant training and were able to describe what chaperoning was and how they would ensure the dignity of people chaperoned was maintained.