Drs Leung, Mallick, Sherrell & Hobbs

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

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on the best available evidence. At our last assessment, we rated this key question Inadequate. At this assessment, the rating has changed to Good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this. During our assessment of this key question we found staff, teams and services worked in a positive way to improve patient outcomes. The practice worked with other care providers to support patients whose circumstances may make them vulnerable. Patients’ needs were assessed, and staff would actively refer patients to social prescribing for support with their wellbeing and social issues and patients with communication needs were supported. Patient consent was sought appropriately.

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.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area.

Staff considered people's wider health, care and well-being needs and worked with partners to support them to access appropriate services. For example, staff used information from patient registration forms to identify and ensure people's needs were being met. Leaders demonstrated how patients who required recall monitoring were supported and managed. This included inviting patients for annual health reviews and long-term conditions reviews in line with national guidelines and Quality Outcomes Framework (QOF). QOF is a voluntary annual reward and incentive programme for GP practices in England.

There were established and effective systems and processes in place to assess, prioritise and review people’s care. Patients were triaged by the reception and nursing team who utilise guidance to escalate risk to members of the clinical team for example people presenting with poor mental health or young children under 5 where their health had declined. Patients' accessibility and communication needs were recorded, and they were supported accordingly. Staff were trained to assist patients through the practice’s care navigation process to ensure treatment was delivered by the most appropriate team or clinician, these incorporated checks for patient's wishes and preferences. The practice had a palliative care register and these patients were reviewed appropriately in bi-monthly multi-disciplinary meetings. Staff had access to the future care planning templates on the practice clinical records system which incorporated checks for patient’s wishes, mental capacity and any treatment escalation planning. The practice had a duty system to ensure patient results such as diagnostic, pathology and other secondary care correspondence was reviewed in a timely manner. We saw evidence of a workflow audit carried out on a weekly basis as a safety netting process to ensure patient results were not left unactioned and any abnormal results were processed urgently.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area.

Staff told us they received regular clinical supervision to ensure their clinical decisions were reflective of national legislation, evidence-based good practice and required standards. We saw evidence of clinical supervision audits for non-medical prescribers which reviewed a randomised sample of cases on a routine basis as part of checks to ensure prescribing was appropriate. Staff told us they had access to training and learning opportunities and were supported with their professional development to ensure they remained up to date with current practice.

There were effective systems in place to identify, share and embed best practice. Regular audits were conducted on administrative processes such as two-week wait cancer referrals to ensure patients had access to effective and timely care and treatment. Management meetings were held fortnightly to discuss the performance of staff and propose and introduce changes to the service. The practice had systems and processes in place to keep clinical staff up to date with current evidence-based practice. Our review of the clinical searches of patient records showed that patients were being effectively and safely managed in relation to their long-term conditions. This included monitoring requirements in line with national guidelines.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area.

Staff and leaders told us about services they worked closely with. This included a variety of local organisations, including those in the voluntary and community sector. Staff told us that they had access to the information they need to appropriately assess, plan and deliver people’s care, treatment and support. In particular, people transitioning between services. Staff told us they had the appropriate information to plan, refer and receive subsequent results following referral. Leaders told us that practice communication such as service updates and pathways with local care providers were sent to staff via email. The practice had demonstrated that views from staff and people were listened to and acted upon, such as actions taken in response to feedback from people. For example, feedback from people who used the service stated that relevant staff and teams were involved in planning and delivering people's care and treatment. Staff told us they worked collaboratively to understand and meet people's needs. We saw evidence of this through the review of surveys about preferences of accessing care and how continuity was managed between staff.

Feedback from the NHS Hampshire and Isle of Wight Integrated Care Board indicated no concerns in this area. The practice worked alongside external stakeholder services such as the community mental health team to support vulnerable patients through treatment planning as part of a multi-disciplinary team. Feedback from the community mental health team highlighted the outcomes for people were positively managed and care and treatment protected them from harm where possible. Learning was shared across staff based on regular evaluation of care. The practice had worked with local care homes to provide care and treatment for residents in the local area. Feedback from the care homes indicated that people had access to timely care and the practice home visiting team were able to provide urgent and acute care effectively.

We saw evidence that the practice shared information with other teams and services, and this included any reasonable adjustments patients required. External professionals were invited to relevant meetings. Meeting minutes were routinely shared with relevant staff members. During our review of the practice’s clinical records systems, we found examples of effective plans for the transition of patients across multiple services. Referrals and discharge summaries were managed appropriately and considered people’s individual needs, circumstances, ongoing care arrangements and expected outcomes.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area. Feedback from patient surveys and from the National GP Patient survey demonstrated that people had confidence and trust in the healthcare professional they saw or spoke to and were involved in decisions about their care and treatment in line with local and national averages. We saw examples of feedback trends from the practice Friends and Family Test (FFT) survey which indicated people were able to access local support and initiatives via the practice, with positive outcomes for wellbeing and mental health.

Leaders told us about the ways in which they supported patients to manage their health and wellbeing, and to live healthier lives. This included referral to a team of social prescribers and encouraging patients to attend health checks and reviews. Staff were aware that uptake rates for childhood immunisations and cervical screening were lower than local and national averages and were taking steps to improve this. For example, staff were working closely with partners in local voluntary and community organisations who were well placed to relay health information to their populations. Staff demonstrated they were aware of the practice safety netting mechanisms to inform and educate patients on what to look out for should their condition deteriorates, such as digital flags in patient care records highlighting any specific needs. During our clinical records review, we found consultation records documented this advice.

People were involved in regularly monitoring their health, including health assessments and checks where appropriate and necessary with health and care professionals. We saw examples of healthcare initiatives to support the practice population including mental health projects with the community hub and local school education sessions for children regarding health and wellbeing. Daily home visit appointments were available to those patients who were vulnerable. The practice had processes in place to ensure patients residing in local care homes could raise urgent care requests and access to treatment via dedicated appointment slots in addition to routine weekly ward rounds. We noted the practice had long-term plans in place with the local council and integrated care board through the Bordon regeneration scheme to incorporate primary care services from a new health hub development. The practice had strong links with the primary care network (PCN) to share services and healthcare provision for the practice population. We saw evidence of regular monthly meeting minutes which highlighted the strategic ambitions of the local primary care teams. There were additional roles reimbursement scheme (ARRS) staff that supported the practice, in which patients could be referred into, with booked appointments, such as mental health practitioners and first contact physiotherapists. We found the practice had a dedicated social prescriber within the PCN and saw examples of various local health initiatives and referral options such as a menopause café; young carers support; military veterans advice; domestic abuse services and homeless help support.

We could not collect sufficient evidence to score this evidence category.

Staff we spoke with could clearly outline the systems in place to recall and review patients and understood their role in this process. They told us how they took a proactive approach to encourage patients to attend for long-term condition reviews and other health reviews such as cervical screening, breast screening and childhood immunisations. Staff told us they monitored peoples' care ensuring they booked follow up consultation of people’s care, requesting additional interventions such as blood tests to continuously improve patient outcomes.

There were established and effective systems in place to identify and monitor people’s outcomes. This was achieved through the quality outcome framework used by NHS primary care services. The practice utilised the Gold Standard Framework (GSF) to support their staff to provide practical and evidence-based end of life care. We identified regular multi-disciplinary meetings were held which included community and end of life nurses and social prescribers. Actions were recorded within patient records as a result of meeting discussions and care and treatment plans were risk rated based on the clinical vulnerability of patients. We found effective processes to ensure all patients with a diagnosis of cancer had regular reviews in line with national guidelines. Recall systems were in place to support patients receiving timely care and we found the GP lead for this area was supported by nursing and administrative staff.

The practice had carried out regular cancer care reviews via telephone and face to face appointment. People received further support and information packs were shared by the practice which included an invitation to discuss care needs, mental health support such as counselling, signposting to hospice care and referral links with the social prescribing team. People with long-term conditions received regular management plans and reviews with reasonable adjustments including extended appointments to discuss care and treatment. The practice had carried out Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) and personalised recommendation for clinical care in emergency situations (ReSPECT) audits to ensure patients were regularly reviewed and these records remained accurate and up to date.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area.

Staff told us there were processes to record and document patient consent to treatment prior to intimate examinations. Where appropriate mental capacity assessments were conducted, support was given to people to understand and fully engage in their care. Processes were in place to support patients to make informed decisions about their future, and to review patients at the end of their lives. We saw that DNACPR and ReSPECT forms were completed in line with guidance and with the input of patients and their carers.

There were established policies and procedures in place to ensure staff knew and observed best practice in recording and delivering care. They audited their consultations and interventions to ensure these were observed. We checked clinical records and saw staff had appropriately recorded patients consent in their records. Patients were offered a chaperone when carrying out examinations, we saw posters displayed in the practice informing patients of this. There were suitable arrangements to ensure staff were aware and trained to obtain and record consent for young people and for the consideration of capacity to make decisions (Gillick competency). We identified the practice also had processes in place for specific consent of sexual health relating to contraception, in line with national guidelines (Fraser guidelines).