Spinney Hill Medical Centre

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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.

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 79 (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.

People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Practice staff were aware of the needs of the local community and adapted to patient needs if necessary. Reception staff used flags within the care records system to highlight specific individual needs, such as the requirement for longer appointments or translators to be present. Staff checked people’s health, care, and wellbeing needs during health reviews. There were leads within the practice for specific health conditions who would monitor registers and arrange reviews for these patients. Clinical staff used templates when conducting care reviews to support people’s wider health and wellbeing. The practice had a high prevalence of diabetes within its population, where the practice specialist diabetes nurse would support these patients. 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. Patients who were registered carers were offered carer reviews to ensure their needs were being met. We saw that checks were well documented including physical and mental health needs of patients including lifestyle advice. NHS health checks were regularly carried out within the practice to detect any patients at risk of developing diabetes, and other health conditions. These were offered at weekends to try and promote uptake. The practice worked with a community pharmacy to encourage patients to have blood pressure checks to identify any patients who may need more investigations.

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.

Guidance updates were documented and discussed promptly during the practices weekly teaching and learning meetings. Any updates would also be disseminated to relevant staff to ensure staff were up to date with evidence-based guidance and legislation. The practice is a training practice and was passionate about upskilling staff to ensure they delivered care in line with correct guidance.

During our review of the clinical system, we saw that the practice was delivering care in line with current guidance. We saw that patient receiving documented reviews of their care and treatment plans, along with systems in place to follow up any patients who had exacerbations of their long-term conditions.

The service worked well across teams and services to support people. They made sure people 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 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.

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 were aware of risks to patients’ health, and we saw evidence of them being signposted to other resources or providers for support such as weight management or smoking cessation. The practice offered health checks to capture patients who may be at risk of developing a long-term condition and for those with caring responsibilities. The practice regularly reviewed vulnerable patients, including external support if necessary for patients such as those patients who were in the last 12 months of their lives. These patients were also discussed at wider PCN meetings under the gold standards framework to share learning and promote better support within the area for vulnerable patients. The practice had access to a social prescriber to support patients with additional needs to support welfare.

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.

We reviewed the practices unverified data for cervical screening and found the practice were meeting national targets for screening and immunisations. The practice had implemented a lead nurse to increase uptake of appointments who invited patients in for discussions around screening and immunisations, followed up any non-attendances and educated patients in their own language around the importance of attending. The practice was able to demonstrate the improvement since the lead nurse had started within the practice and had now exceeded the target requirements. 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.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded where required and practice had discussed mental capacity assessments in teaching and learning meetings. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation and were well documented and reviewed when changes were made.