Manor Park Medical Practice

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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

During our assessment of this key question, we found the practice monitored and improved outcomes for patients by carrying out clinical audits. Staff, teams and services worked in a positive way to improve patient outcomes and worked with other care providers to support patients whose circumstances may make them vulnerable. The practice were also able to make referrals to their social prescriber, allowing them to attend to the patient's individual needs.

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 national GP patient survey carried out from January to March 2024 had 105 responses. Findings from this GP patient survey show 90% of patients surveyed felt their needs were met during their last GP appointment.

Leaders told us they were passionate about ensuring patients care was reviewed and updated regularly to provide high level care. Staff told us they placed importance in providing individualistic care to patients to ensure they were providing effective care. For example, reception staff knew when to organise an interpreter or when to organise a longer appointment time for a patient. The social prescriber at the practice told us he had regular communication with the connections in the community such as local authorities and police to further understand the needs of the practice population.

Processes were in place to ensure patients' needs were met, involving them in their care and treatment options and systems were in place to support those with additional needs. We reviewed patient records to assess the management of patients with long-term conditions. This showed that patients were monitored and managed appropriately. Care plans such as dementia care plans, RESPECT advanced care plans and asthma management plans were provided to patients. An on-call GP was always available to address concerns, review results and arrange medicine reviews. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to the social prescriber.

The evidence we reviewed did not show any concerns about people’s experience regarding delivering evidence-based care and treatment at this practice.

Staff we spoke with were knowledgeable about guidance updates and had systems in place to ensure prescribing and treatment offered was in line with national guidance. Feedback from leaders showed they worked to ensure all clinical correspondence and tasks were up to date. Patients had access to appropriate health checks and assessments and were directed to relevant services when they needed additional support. For example, patients assessed as at risk of developing a long-term condition. People were encouraged to be involved in monitoring and managing their own health and if appropriate, could be referred to the social prescriber.

We saw effective processes in place to ensure patients received care and treatment in line with good practice standards. When reviewing the clinical systems, we saw records of evidence-based treatment being offered. The practice had a process for managing safety alerts and used a safety alert log to record actions taken in response to alerts. We conducted a review of patient care records and found that all had been contacted with the necessary information, except patients on a medicine typically prescribed to treat epilepsy. These patients had been made aware of the risks during pregnancy and advised to contact their specialist or prescriber. However, they had not yet had their pregnancy prevention plan signed. The practice were keen to rectify this and told us that the new risk acknowledgment form will be updated during each patient’s next annual appointment.

The evidence we reviewed showed patients felt there was clear communication between staff and services to enable smooth transitions during referral processes and all staff knew the relevant information needed at the time.

Staff told us they recorded all patient notes on their record to ensure all staff were aware of the patient’s care, treatment, tests and conversations. Staff also told us that GPs worked with other health care professionals to deliver a coordinated package of care, particularly those with complex needs. The practice identified patients with caring responsibilities and had signposted to other services to support their needs. There was also further health information, including various health services available through patient registration, notice boards and leaflets.

Partners told us about roles and responsibilities to ensure smooth transitions for patients. Dr Wadhwa is the Clinical Director for the Primary Care Network (PCN). The practice is involved with PCN initiatives (e.g. enhanced access services, addressing health inequalities work and the implementation of cardiorespiratory diagnostics in primary care). Data sharing agreements are in place with other practices in the PCN and other organisations to improve patient care. The practice has evidenced social services and health visitors updating patient records. The practice have been accepted to participate in the Modern General Practice scheme, enabling staff to access training to help improve care navigation and to support patients in using the NHS app. A Patient Participation Group (PPG) is in place and the practice has a good relationship with this group.

All staff from various teams and services that were involved in assessing, planning and delivering care and treatment worked collaboratively to ensure people's needs were met. The social prescriber was also able to help navigate patients to the most suitable services.

Patients that attended a recent open day that raised awareness about common health concerns, provided accessible healthcare services, and encouraged community engagement deemed the event a success and wanted to express their gratitude for the opportunity of diabetes and atrial fibrillation screening alongside flu vaccinations. Patients that speak Asian also expressed their appreciation for Dr Wadhwa’s radio shows, enabling them to learn about various health concerns.

Staff and leaders told us they encourage patients to take an active approach in supporting their own health and wellbeing while providing the resources to do so. The social prescriber told us they are engaged and passionate in signposting patients to services and supporting vulnerable patients. Dr Wadhwa tells us he does health promotion talks and events about common health issues held at local community centres, health fairs, temples, churches and mosques. Dr Wadhwa also hosts a show on the Sabras Radio (the biggest Midlands Asian radio station). Both promoting health education and awareness, discussing topics such as diabetes, high blood pressure, strokes and promoting smoking cessation, weight management, immunisations.

During our clinical searches, we found effective medicine reviews and detailed medical records showing us how patients had been supported. Patients are contacted and encouraged to participate in screening programmes. The practice staff were knowledgeable within their roles and often referred to the social prescriber when appropriate. There was also a wealth of self-help tools and guidance available in reception.

We could not collect specific evidence from patient feedback to score this evidence category.

Staff told us audits were completed to monitor outcomes for patients. The provider submitted various clinical audits covering areas such as contraception, osteoporosis, sore throat antibiotics use and the prevalence of non-diabetic hyperglycaemia. The diagnosis of diabetes has increased over the years due to the very extensive diabetes care program conducted by the practice and the robust checks carried out during routine check ups such as blood pressure and hba1c. The large majority of patients are provided the support they need at the practice including insulin initiation and management support, whilst only referring a small number of patients to secondary care. The staff also told us they are pro active by calling the patients ahead of their review to ensure patients receive the care they need in a timely manner. The practice prevalence of non-diabetic hyperglycaemia has increased from 81 in January 2022 to 961 in July 2024. This means that these patients can be given advice and followed up appropriately to reduce their risk of developing diabetes.

Staff and leaders demonstrated effective systems and processes to monitor and improve outcomes. The clinical searches reviewed long term conditions such as asthma, diabetes and hypothyroidism to ensure medical reviews were completed appropriately. All searches looked at 5 patient records and found that all patients had received reviews. The practice evidenced or in the case they hadn’t, evidence was seen of the practice contacting them to arrange monitoring.

Clinical searches we completed showed systems in place for monitoring patients with long term conditions and those on high-risk medicines. There was a structured system in place for inviting patients in for their long term conditions annual review. At the time of the onsite assessment, the practice had done 80% of the diabetes reviews for the current QOF year. Since our onsite assessment visit, the practice have told us that they have achieved number one practice in Leicester City for the eight care processes for good diabetes care. The practice were calling in patients to review their blood glucose level every 3 months instead of the standard 6 months whilst prioritising an early review for the patients with a higher blood glucose level. The practice employs a local diabetes specialist for 2 sessions a month to provide support for complex patients and the practice is also able to initiate insulin. This proactive approach ensures that patients are receiving the treatment needed in a timely manner.

Patients told us staff went through the risks and benefits of the care and treatment. They were given information verbally and signposted to written information for additional information. Patients were satisfied and felt GPs fully explained their treatment and would not proceed with the treatment if consent was not given.

Staff told us they knew the importance of ensuring people fully understood what they were consenting to before the care or treatment was delivered. Staff told us they were able to adapt information about care and treatment to ensure all patients were supported when making informed decisions.

The staff had undertaken online training for consent to care and treatment. Staff would undertake mental capacity assessments when needed and there were templates on the practice's system to prompt them to gain consent. Consent was recorded on the patient record. Staff also evidenced their access to medical records policy, including request forms for online access to health records in line with the UK general data protection regulation.