Clare House

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 have rated the practice as Good for providing effective services because: People received appropriate care and treatment. Their needs were assessed and appropriate care was provided, in line with best practice and national guidance. Care was coordinated with other services when needed and people were supported to self manage their conditions whenever possible. The practice provided us with evidence to demonstrate that these areas had been addressed. Patient had been invited in for reviews and blood tests where needed. Coding discrepancies on patient records had been reviewed and amended, to ensure they were standardised. (Clinical coding means applying unique and precise 'codes' to various aspects of patient care to enable consistent understanding and sharing of clinical information).

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.

We looked at potential missed diagnosis of chronic kidney disease as part of our clinical searches. We found 9 patients potentially had a missed diagnosis and looked at 5 patients records in detail. We found that these patients were borderline for a diagnosis of chronic kidney disease and had other conditions. The practice was regularly monitoring these patients for signs of deterioration in their condition and so that they could provide appropriate care and treatment. We saw that when patients attended for appointments they were addressed by their preferred name. Staff working in the practice had access to interpreters when needed. The self check in screen could be translated into different languages. Information from feedback on care submissions received by us since July 2023 included that patients were seen on the day if needed and there were prompt responses to online requests. Patients also commented that they were updated and informed of progress of referrals made.

The practice had 2 on the day GPs, a paramedic, and an advanced nurse practitioner who dealt with on the day requests. They were able to book in either telephone or face to face consultations with patients following triage. People who had long term conditions were offered annual reviews with staff who had received training appropriate to their role. Staff interviewed said that they had access to relevant guidance on their computers and also had standardised care plans to use when carrying out assessments. When needed shared care arrangements were in place with secondary care providers, for example for patients needing support with substance misuse. People who lived in care homes that the practice provided a service to had weekly ward rounds with the same GP so that continuity of care was promoted and their needs addressed and health conditions monitored. This also enabled new residents to be seen easily and their health needs assessed. Staff were able to describe the process for consent and the need to make sure that a person had capacity when making a decision. If needed relevant people were consulted, such as people who held power of attorney for health and relatives of a person.

Patients’ treatment was regularly reviewed and updated. The practice were in the process of implementing a new recall system. This process included ensuring any blood tests or physical monitoring, such as blood pressure checks, were carried out prior to the review. Systems already in place covered medicine reviews, to ensure medicines prescribed were still needed and were effective. Medication reviews were carried out yearly or every 6 months, depending on the medicines prescribed. Patients with long-term conditions were offered a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care. Prior to the COVID 19 pandemic the practice offered spirometry tests to diagnose people who had breathing difficulties, this had not yet re-started. Meetings minutes from May 2024, showed that this was a service the practice was hoping to re-start, to ensure an accurate diagnosis was made, and appropriate treatment could be given.

People living in care homes had regular visits from named clinicians to promote continuity of care. People with a learning disability were provided appropriate support and the practice liaised with specialist nurses when delivering care and treatment.

Templates used to assess patient needs were linked to national and good practice guidance, such as the National Institute of Clinical Excellence and the Quality Outcomes Framework. Information on best practice was cascaded to staff at clinical meetings and via newsletters and emails.

Patient review meetings were held, which included relevant members of the multi-disciplinary team. There was a set agenda for these meetings. Minutes showed that areas discussed included those patients receiving end of life care; new cancer diagnosis; and pain management. There were details on other teams involved in patient care, such as palliative care teams. Specific meetings had been set up to discuss the care and treatment of patients with long term conditions. Information shared included latest clinical guidance, for example for managing high blood pressure and management of diabetes. Discussion was held around what blood tests were needed for annual reviews, as there were differences between quality outcome measures and other good practice guidance. These discussions focused on coordinating monitoring and having a standard list of tests to be carried out, to avoid the potential of relevant tests not being carried out for a review. We saw evidence which showed this had been put into place.

There was no specific patient feedback on this area.

Staff understood the patient population and their needs and were able to offer a holistic approach to support them. Staff provided appropriate and timely information to patients to help them cope emotionally with their care, treatment, or condition.

Staff worked well together and liaised and communicated with external professionals. Systems and processes had been developed to share information to promote the coordination of care and treatment.

Shared care records were in place when needed and out of hours GPs were able to access a patient’s Devon wide care plan, which had a summary of their conditions and current treatment. Patients received consistent, coordinated, person centred care when they moved between services. Information relating to individual patients from external health providers was uploaded to their clinical records in a timely way. The practice had identified a backlog in summarising records and taken action to ensure the backlog was cleared in a timely manner, while processing new information.

Feedback received from the patient participation group (PPG) mentioned carers, who were signposted to local charities for support and following up on patients who regularly did not attend for appointments to provide support. (PPGs are generally made up of a group of volunteer patients and practice staff who meet on a regular basis to discuss the services on offer). The uptake for cervical screening was 73.5%, which was below the national target of 80% (30/6/223). Patients were offered opportunistic cervical screening when possible and could access this service outside of core hours, in order to improve uptake.

The practice identified people who may need extra support and directed them to relevant services. This included patients in the last 12 months of their lives patients at risk of developing a long-term condition and carers. Staff encouraged and supported people to be involved in monitoring and managing their own health. The practice had social prescribers who were able to signpost people to support in the community. They also ran groups where people could meet and learn about ways they could self manage their condition. These included a weekly goal setting meeting and a 6 week programme for patients with long term health conditions and mild mental health needs.

Healthy living information and a carers’ notice board was in the reception area providing details of what types of support were available. Information was also available on the practice website. People were offered appropriate health assessments and checks. People with a learning disability were offered longer appointments when needed for their annual review. People who used the service were offered vaccinations in line with national guidance. The practice liaised with the local school and offered welfare meetings and signposted young people to services such as counselling. People who were housebound were offered reviews in their own homes; and people who had no fixed abode were able to register at the practice and receive care and treatment.

We did not receive specific feedback on this area from patients.

Peer reviews of prescribing practice were carried out to encourage prescribers in their decision making process to deliver safe, evidenced based and cost effective prescribing and to identify and learning needs. The practice had a dedicated care home team who undertook regular visits to local care homes, to provide continuity of care and timely treatment. Complex patients were discussed in daily huddles and clinical meetings; minutes confirmed this.

There was an audit programme in place. For example, an audit was carried out in January 2024 to find out whether trans men had been recalled for cervical screening.(A trans man is a man who was assigned female at birth. Trans men have a male gender identity, and many undergo medical and social transition to alter their appearance in a way that aligns with their gender identity). A search was run on all transgender patients registered at the practice, to ensure the correct codes and diary entries were in place so that invitations could be sent to relevant patients.

Annual reviews of patients with chronic health conditions such as COPD, a breathing condition and asthma were undertaken. Medicines which required monitoring were managed by the recall team in line with national guidance and when needed prescriptions intervals were reduced until a patient attended for a review. The practice adhered to national guidance on safe and effective use of medicines. The practice had a programme of targeted quality improvement and used information about care and treatment to make improvements. The practice regularly reviewed unplanned admissions and readmissions and took appropriate action. A range of clinical meetings were held, these included monthly patient review meetings; monthly clinical meetings and a monthly governance meeting. Meetings minutes showed that treatment and clinical outcomes for patients were discussed, for example treatment for eczema and the impact of unidentified mental health needs on people presenting with a physical condition. Governance meetings demonstrated that standard operation procedures were discussed before being put into place, for example a diabetes management policy. Also discussed were results from clinical audits and learning and actions needed, such as making sure people who lived in care homes were correctly coded, so that they could be identified easily.

Clinicians supported people to make decisions. Where appropriate, they assessed and recorded a person’s mental capacity to make a decision. Information from the national GP patient survey showed a total of 98.7% of patients stated that during their last GP appointment they were involved as much as they wanted to be in decisions about their care and treatment compared to the expected outcome of 90.3%.(positive variation). Patient feedback we received included that people considered they were treated with kindness and respect and consulted about care and treatment.

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. Consent from people who used the service for care and treatment, was obtained either verbally or in writing and recorded on their records. Staff were able to explain the process for seeking consent and how they would gain consent from people aged under 18 years old. They could describe how they would assess a person’s capacity to make decisions.

The consent policy details types of consent, for example informed or, voluntary. It outlined the process for obtaining consent and what needed to be recorded. When people had minor surgery written consent was always obtained and people were given appropriate information on the procedure they were having. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were made in line with relevant legislation and were appropriate.