Royal Primary Care Brooklyn

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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 people’s care and worked with other services to achieve this. This is the first assessment for this service since its registration with CQC. This key question has been rated as Good.

This service scored 67 (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. Staff checked people’s health, care, and wellbeing needs during health reviews. There was a system in place to follow up people with long-term conditions. Effective systems were in place 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. Feedback from people using the service was mixed. Some people felt involved in any assessment of their needs and felt confident that staff understood their individual needs. Some people gave examples of when they felt their care needs had not been met. A representative from a care home where the practice provided care and treatment to people was very positive about the weekly ward round provided by the practice. They told us that the practice provided monthly, face to face multidisciplinary meetings to review the care and treatment of people living in the home. They gave examples of positive outcomes for people as a result of these meetings.

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 mostly in line with current guidance. However, we found that steroid cards were not always issued to people prescribed steroids following an exacerbation of their asthma.

Feedback from staff was extremely positive about how staff and teams worked together to provide effective care and support for people. They told us there was strong and effective communication across all staff sectors, a very positive attitude and everyone was willing to help each other out. 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 such as the Primary Care Network. The practice was part of Royal Primary Care (RPC) which operated as a division of primary care for Chesterfield Royal Hospital NHS Foundation Trust. This supported joint working and learning across all 4 practices within RPC and the Trust.

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, reduced their future needs for care and support. For example, NHS health checks, long-term condition reviews and advise on national health priorities such as diet, lifestyle and smoking cessation. Staff focussed on identifying risks to people’s health, including those in the last 12 months of their lives, people at risk of developing a long-term condition and those with caring responsibilities.

The service routinely monitored people’s care and treatment to continuously improve it. 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. There was a suit of clinical audits to improve outcomes for people. The provider ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. Data showed that the practice met national targets for childhood immunisations. The uptake rate for cervical screening of 70% (NHS Digital - Cervical Screening Programme Coverage Statistics, 30 June 2023) was below the national target of 80%. The practice provided recent data to support improvements in the uptake of cervical screening showing it was slightly above the national target. Although the data has not been verified, it demonstrated improvement in the uptake. Royal Primary Care (RPC) had identified the number of people across their 4 practices that had failed to attend for cervical screening. A cancer champion and dedicated team followed up people who had failed to attend cancer screening and promoted the benefits of screening appointments. RPC’s analysis of their cancer screening data showed that out of 1,489 people, 804 people continued to not attend, 317 declined, 328 had normal results and 40 had abnormal results. When a person had been recontacted and attended screening which showed an abnormal result, a bead was added to a jar to demonstrate the impact of the team’s work. Clinical staff had developed videos about prostate exams, breast and cervical screening to encourage non-attenders to attend their appointments.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. Policies were in place to support staff when obtaining consent which reflected national guidance. Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded in peoples’ records. Our review of peoples’ records showed that do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and made in line with relevant legislation.