Castle Place 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

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. However, improvements were required.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good. We found; one breach of the legal regulations in relation to safe care and treatment. People’s needs were not always appropriately assessed, in relation to monitoring of medicines and long-term conditions.

Following our clinical searches, the provider sent us evidence of improvements they were intending to make in response to our findings. For example, implementing an action plan to review the clinical records of people identified and take further clinical action (where required) within a 6-week timescale.

We will review these improvements at our next assessment.

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 service made sure people’s care and treatment were effective. They appropriately checked and discussed people’s health and care 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. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. We saw evidence of audits of social prescribing, which showed positive outcomes for people (Social prescribing isa way to improve a person's health and well-being by connecting them with non-medical support in their community).

The practice worked closely with community pharmacies for medication reviews and minor ailments via promotion of the Pharmacy First service, and structured medication use. To ensure clinical information attained by these services, were known to the GPs and nursing staff.

As part of our assessment a number of set clinical record searches were undertaken by a CQC GP Specialist Advisor. These search criteria are freely available for practices to access at any time.

We identified during the clinical searches that there were effective reviews and monitoring of patients with asthma and those prescribed disease modifying anti-rheumatic drugs (used to treat autoimmune diseases, particularly rheumatoid arthritis). However, improvements were required.

Our clinical searches identified 155 out of 405 patients on a nonsteroidal anti-inflammatory drug (used to reduce pain, fever, and inflammation) in people aged over 65 years or 75 years, had not been prescribed a proton pump inhibitor (PPI - used to protect the stomach lining when taking nonsteroidal anti-inflammatory drugs (NSAIDs), which can cause ulcers). We reviewed the records of 5 of these and evidence showed this was due to people being discharged from hospital having been commenced on NSAID medicines without the appropriate PPI. The practice had not reviewed these patients once they had been discharged from hospital to ensure they were prescribed appropriate medicines.

Our clinical searches identified 55 people out 1816 people prescribed an Angiotensin-Converting Enzyme (ACE) inhibitors and/or Angiotensin II receptor blockers (used to treat high blood pressure) had not had this recorded. We reviewed the records of 5 of these and found 3 of them did not have this recorded.

We reviewed the records of people with hypothyroidism (also called underactive thyroid, is when the thyroid gland doesn't make enough thyroid hormones to meet the body's needs) who had not had a thyroid function blood test monitoring with the last 18 months. We noted that 23 out of 543 had not had the required blood tests completed. We reviewed the records of 5 of these and found there was no reason recorded for this.

Following our clinical searches, the provider sent us evidence of an action plan they had implemented in response to our findings. This included a realistic 6-week date for completion and showed that several peoples clinical records had already been reviewed as part of this, as well as people having attended appointments for reviews and required testing. Additionally, the service management team were planning to raise NSAID and PPI prescribing with the providers governance team, to reduce the risk of patients being discharged from hospital without the required review of medicines (in line with safety alerts).

Further evidence submitted by the provider showed the 6-week action plan had been effective.All patients who had not had thyroid-stimulating hormone blood test had now been contacted to book an appointment or had attended. People who had not had blood tests monitored on Angiotensin-Converting Enzyme or angiotensin receptor blocker, have now have had their blood checked. For both cohorts of people, it had been recorded in their clinical records where multiple requests to attend had been made and they had failed to attend or respond. All people on a NSAIDs aged over 65 years or 75 years who had not been prescribed a PPI had either been reviewed; had been reviewed and appropriately assessed for whether the risk of PPI use is greater than not; or if the person had declined this medicine being prescribed. The prescribing of PPIs at hospital discharge has been raised with the Deputy Medical Director at the hospital trust, who are reviewing issuing advice and guidance to staff about this.

The service always 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. They worked to develop evidence-based good practice and standards.

Clinical staff had access to relevant national and formulary guidance, as well as local policies/guidelines and used this information to help ensure that people's needs were met.

Staff told us they received regular updates from leaders at the service. Where there were changes in process guided by learning at the service, staff told us that they were informed and involved in implementing changes.

As part of our assessment a number of set clinical record searches were undertaken by a CQC GP Specialist Advisor. These search criteria are freely available for practices to access at any time.

We identified during the clinical searches that there were effective reviews and monitoring of patients following receipt of Medicines and Healthcare products Regulatory Agency (MHRA) alerts. However, improvements were required.

We reviewed the records of patients prescribed a medicine that eases the symptoms of an overactive bladder, which is contraindicated in patients with severe uncontrolled hypertension (high blood pressure); in line with MHRA advice about regular monitoring because of cases of severe hypertension. We identified 8 out of 71 people, did not have their blood pressure recorded routinely in their records. The service had conducted an audit of improvingthe management of hypertension (high blood pressure) and related long-term conditions (LTCs) in 2023.All staff were trained on blood pressure (BP) targets and the process for home blood pressure monitoring was improved as a result.Quality and Outcomes Framework(a voluntary incentive program in the UK that rewards GP practices for providing high-quality care to patients, particularly for managing chronic conditions, public health concerns and preventative services)data over the past 3 years reflected significant improvement in population BP control due to these changes; with increases noted of between 15-31% for people with hypertension or a related LTC having had their blood pressure checked in the 12 months.

Following our clinical searches, the provider sent us evidence that all these peoples clinical records had already been updated to show recent blood pressure monitoring.

Staff were aware of the need to complete accurate and full records, such that information did not need to be repeated by patients.

Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. Care and treatment for patients in vulnerable circumstances was coordinated with other services. There were established pathways for staff to follow to ensure patients’ needs were met.

There was no feedback of concern in relation to how staff, teams and other services worked together from partner organisations.

The service ensured that care was delivered in a coordinated way and took account of the needs of different patients, including those who may be vulnerable because of their circumstances.

The service provided GP services to a care home and provided twice-weekly “ward rounds” for 55 people. We were told that the manager of the care home provided the service with information about which people required a review or consultation in advance of the ward round, so that care and treatment could be provided in an effective way.

There were clear and effective arrangements for booking appointments and transfers 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. For example, sending annual text reminders to people who smoke, reminding them of the benefits of stopping smoking and the support available via the practice to do this.

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 service had not always met national targets for cervical screening. However, evidence showed the practice had now achieved these due to making screening services more accessible. Cervical screening appointment availability had been added to enhanced access hours; meaning appointments were available after 6.30pm on certain dates and occasional Saturdays. We also saw that reception staff had the freedom to convert a routine nursing appointment into a cervical screening appointment to further increase access.

The service had achieved the average national targets for all childhood immunisations.

The provider submitted evidence of 22 clinical audits. These covered medicines, health conditions and mental health/well-being monitoring, which they had carried out to improve outcomes for people. Leaders and staff told us that audits were discussed at clinical meetings; this was confirmed in the minutes of the meetings we reviewed, which showed the findings were shared and learning outcomes/changes to practice or policies/procedures were cascaded to staff. For example;between 2022 and 2023, the service had undertaken significant work to improve how they provided care and the recall of people with long-term conditions (LTCs). For example, raised blood pressure; newly diagnosed cancer; mental health and learning disability checks; raised cholesterol; heart failure; dementia; cardiovascular disease; diabetes, chronic obstructive pulmonary disease and asthma. The service had a dedicated team of Care Coordinators who managed this system. To ensure people with LTCs needs could be met, the service undertook capacity planning, which enabled care coordinators to work closely with the nursing team and data manager; to ensure that adequate LTC appointment were available, using demand data (known as Performance Assurance (PAF) data) to balance LTC reviews, general nursing, NHS Health Checks, and blood tests. The PPG had received feedback that a more personalised approach to LTCs would be appreciated and add value to people. The service were in the process of working together with the PPG, to establish how this could be achieved.

Patients did not raise any concerns regarding the practice seeking their consent to care and treatment.

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

Consent documentation in relation to minor procedures was appropriately recorded and documented.

Relevant staff had been provided with training in the Mental Capacity Act. The service monitored the process for seeking consent appropriately and patient record searches demonstrated that consent was recorded appropriately. We reviewed Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions for 3 people and found they were maintained in in line with relevant legislation.