Tessa Jowell GP Surgery

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• 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 patients’ care and worked with other services to achieve this.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to good.

Patients 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 patients’ care for the best outcomes and smooth transitions when moving services. Staff made sure patients understood their care and treatment to enable them to give informed consent.

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 patients’ care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Reception staff were aware of the needs of the local community. Digital flags were used 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 patients’ health, care, and wellbeing needs during health reviews. 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 service planned and delivered patients’ 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.

The service worked well across teams and services to support people. They made sure patients 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 patients’ 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 patients to manage their health and wellbeing to maximise their independence, choice and control. The service supported patients to live healthier lives and where possible, reduce their future needs for care and support.

Staff focused 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. The provider had recently held a carers support event with the aim being to provide advice, support and signposting to carers. There was also the opportunity for carers to give feedback about their experiences, so that the practice could provide the right support to patients.

Staff supported national priorities and initiatives to improve population health, including smoking cessation and weight management. The service participated in the Healthy Living Years project which involved using data to predict outcomes for specific patient groups. Patients at risk of long term conditions, such as hypertension and diabetes, were then signposted to appropriate lifestyle advice.

NHS England data from June 2024 showed the practice had not met national targets for the uptake of cervical cancer screening. Screening for eligible patients aged 25 to 49 years was 68% and for eligible patients aged 50 to 64 years was 72.1% (the national target for both groups is 80%). To address this the provider; contacted patients using their preferred communication; followed up non-responders with a minimum of 3 contact attempts; offered flexible appointments including early morning, evening and weekends; allowed patients to book appointments using their preferred method, such as on the telephone, via the appointment app or using the self-book option; and placed alerts on patients’ records so that clinical staff could opportunistically speak to patients about their screening appointments.

UK Health Security Agency (UKHSA) data for the period of April 2023 to March 2024 showed the practice had not met the World Health Organisation (WHO) minimum recommendations for uptake of 3 of the 5 indicators relating to childhood immunisations. To address this the provider; had a dedicated administrator to oversee registration of children and immunisation call and recall; sent reminders via text message and letter; and contacted parents who were vaccine hesitant to provide support and education.

The service told patients about their rights around consent and respected these when delivering person-centred care and treatment. Staff had completed training to understand the Mental Capacity Act 2005.

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.