Hednesford Medical Practice

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

The service had a good learning culture and people could raise concerns. Incidents were investigated. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated and flagged were appropriate to the premises landlord.

There were enough staff with the right skills, qualifications and experience. Leaders made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

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.

The practice used the Electronic Frailty Index (eFI) a risk stratification and prioritisation tool embedded within their clinical system to identify patients with moderate or severe frailty. They used this index tool as well as their local and clinical knowledge. Structured annual medication reviews took place. The practice worked to ensure proactive care for patients identified with moderate to severe frailty in line

with their network contract Directed Enhanced Service (DES) which required Primary Care Networks (PCNs) to deliver proactive multidisciplinary care to complex patients, including those with moderate to severe frailty.

The provider used personalised care and support plan (PCSP) templates which were stored electronically and reviewed. The practice ensured there was multi-professional input, scheduled meetings, a clear referral criterion, and electronic documentation. Continuity of care approach was employed for housebound and people living in a care home setting.

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. However, we did identity a few issues around a lack of a consistent follow up approach for patients with an exacerbation of asthma and prescribed steroids. The provider reviewed the records and put in place monitoring to ensure consistent follow ups. A small number of patients were overdue monitoring, but this was actioned by the provider following our feedback. For example, 1 patient with pre-diabetes who had yet to be electronically coded as a pre-diabetic. This was actioned by the provider following our feedback. Our clinical searches found there were 5 patients with hypothyroidism overdue thyroid monitoring. Risks where patients could be under or over treated for their hypothyroidism. We saw that patients had been contacted and not attended, and the provider had employed a short prescribing system to encourage appointment attendance.

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.

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.

NHS Health Checks were offered to eligible patients aged 40–74 the invitations were electronically tracked and the uptake monitored quarterly. New patients who registered at the service were sent a welcome message and invited to book a health check. Everyone Health was commissioned to carry out these checks and contacted the practice monthly to update patient records with completed NHS Health Checks. A questionnaire was available in the reception area and within each clinical room for patients to provide new information about their weight, height, BMI, smoking status, and alcohol consumption so the clinical staff could update their record with the most up to date information.

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.

The practice had made improvements over the period of 2020 to 2024 towards meeting the national targets for screening and immunisations. However, the cervical screening uptake in women aged 25 to 49 in June 2024 remained below the 80% target at 74.9% and in women aged 50 to 64 70.9%. The practice was able to demonstrate the uptake improvement strategies they had put in place to 2025.

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 provider completed clinical audit which had included the diagnosis and management of vitamin B12 deficiency in 2024. Findings confirmed their initial concern that a proportion of patients in receipt of treatment may be inadequately monitored or investigated. Recommendations for improvement were implemented. For example, an annual recall system for patients with B12 deficiency, including blood monitoring and review of any ongoing need for therapy. They also circulated a flowchart summarising the best practice guidance for vitamin B12 investigation and management.

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. The provider had completed clinical audits on DNACPR forms between April to October 2025. The findings demonstrated that the template used was fully completed for all patients. Areas for improvement suggested ensuring all completed copies of these forms were also held on the patient record and a clear alert within all these records that the form was in place.

Staff had completed learning disability and autism training to at least Tier 1 and for those yet to complete Tier 2 training this was planned. The lead GP completed train the trainer training to facilitate staff training to Tier 2 in the absence of timely availability of this training for their staff.

The provider maintained an advocacy and a consent policy, and all clinical staff had completed Mental Capacity Act (MCA) training, with non-clinical staff training proposed.