Archived: Glemsford Surgery

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 Good. At this assessment, the rating remains the same.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice made sure people’s care and treatment was effective by assessing and reviewing their health, care, well-being and communication needs with them.

Feedback from people we spoke with about using the practice was positive. People told us they felt involved in assessments of their needs and were confident that staff understood their individual requirements. We found reception staff were aware of the needs of the people in their local community. When reviewing peoples records during the remote clinical searches, we found staff used digital flags to highlight specific individual people’s needs for example, the requirement for longer appointments or for a translator to be present during care and treatment. We saw staff checked people’s health, care, and well-being needs during health monitoring and medicine reviews. Clinical staff used established best practice clinical templates when conducting health reviews to support people’s wider health and well-being.

Patients with long term conditions were provided appointments of 40 to 50 minutes for their review with the nursing team. People with a learning difficulty were also provided 40 minute appointments as part of their annual health check.

We were told the introduction of the care coordinators had helped develop a more structured approach to peoples care. The practice had access to mental health staff, health and well-being coach and a occupational therapist who attended once a week.

A GP visited the local care home every week and on the day of our site visit, for example, 17 care home residents were seen. Feedback from the care home was positive and the GP felt calls from the care home had reduced in the last 6 months since they had started to provide regular weekly visits.

The provider had effective systems to identify people with previously un-diagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The people we spoke with during the assessment told us they were satisfied with the way the practice delivered people’s care and treatment, including discussing their needs and what mattered to them. Evidence seen showed this was done in line with legislation and current evidence-based good practice and standards.

Clinical staff used clinical evidence based templates when conducting health reviews to support people’s wider health and wellbeing. People were recalled according to the month of their birth. People with multiple long-term conditions were reviewed where possible, during one longer appointment. Arrangements were in place to coordinate any tests people required so that results were available at the time of their review appointment.

We observed during the clinical searches that the practice delivered evidence-based care with effective arrangements to invite people for monitoring and required reviews.

The practice worked well across teams and services to support people. They shared assessments of people’s needs when they moved between different services. This ensured people only needed to tell their story when they 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.

Arrangements were in place for practice teams to support each other during periods of staff sickness, annual leave, and busy periods of the day within the practice. For example, staff were trained to support receptionists at times of peak telephone demand.

Stakeholder feedback was positive, and an example given was the recent improvements made with the regular care home visit arrangements.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. The practice supported people to live healthier lives and where possible, reduced their future needs for care and support.

People who provided feedback had no specific views or concerns in this area. Representatives from care homes told us people received general and specific health checks, and a GP visited weekly.

A range of services were available through the PCN practice’s employed staff to support people to improve their health and wellbeing. This included for example, first contact physiotherapists, social prescribers, care coordinators, a health and well-being coach and a mental health occupational therapist, who were available on different days and times at the practice. NHS health checks were offered to people aged 40 to 74 years. Healthy living information was available in the waiting room, around the practice and on the practice website. There was a well-placed information board in the waiting room exampling dementia care support, and services available to the local population.

Clinical staff described how they supported national priorities and initiatives to improve population health, this included stopping smoking and tackling obesity. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

Staff identified risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term conditions and those with caring responsibilities.

The practice 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.

Practice staff had worked to improve the uptake of childhood immunisation and had achieved the World Health Organisation target of 95% for 4 of the childhood immunisation indicators and were focussed to improve the remaining indicator.

The nursing team were working towards improving their cervical screening recall system however, we saw they had missed the target of 80% achieving 79.3% in the most recently published data available. Arrangements were in place to follow up people when they did not respond to an invitation or attend their appointment.

The practice told people about their rights to consent, and respected people’s wishes when delivering person-centred care and treatment.

Feedback provided by people we spoke with told us they felt at ease during consultations, were listened to, procedures were explained well, and consent was requested. Feedback from people who had undergone procedures at the practice showed high satisfaction.

Clinicians told us they supported people to make decisions, and where appropriate, assessed and recorded a person’s mental capacity to make a decision as part of the consent process. Clinicians told us they always obtained consent from people and offered a chaperone where appropriate, which was recorded on the clinical system. We saw posters attached to treatment room doors to remind people they could request a chaperone.

Staff who carried out chaperone duties were trained for the role and had received a disclosure and barring (DBS) check.

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.