Dr PV Gudi and Partner

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

At the last inspection we found cervical screening targets remained below national targets and the leadership team were unable to demonstrate they had clear processes in place to address poor performance or monitor staff in clinical roles. At this inspection, we found that improvements had been made and there were systems and processes for assessing needs, delivering evidence-based care and treatment, monitoring and improving outcomes and supporting people to live healthier lives. We saw evidence of how staff, teams and services worked together to provide effective care to patients.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice used codes and alerts on patients records to highlight any communication needs and any impairments. The practice had systems and processes in place to identify people’s needs and preferences during the registration process. We found that systems and processes to ensure the safe, care and treatment of patients had been strengthened and there were processes to keep clinicians up to date with current evidence-based practice. We found pathology, cytology and other test results via workflow had been reviewed in a timely manner, and there were effective systems and processes in place to ensure that staff had the sufficient information to inform their treatment decisions. We found the practice held registers which were reviewed to prioritise care for their most clinically vulnerable patients. For example, we reviewed a patient with a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) record to consider whether the DNACPR had been prepared and found this had been reviewed and agreed appropriately.

We found the majority of people with long-term conditions were offered a structured annual review to check their health and medicines needs were being met. The remote clinical searches that we undertook of the practice’s clinical records system showed the monitoring of people with some long-term conditions were followed in line with National Institute for Health and Care Excellence (NICE) recommendations. For example, we identified 212 people with hypothyroidism, a condition which results in low activity of the thyroid gland. We reviewed 5 clinical records and found 2 people had not received the appropriate blood monitoring, however following the assessment, the practice had taken appropriate action. Further review of the clinical records identified 105 people with diabetes whose last blood glucose reading was over 75. We reviewed a random sample of 5 records and found that 2 people were overdue a medicine review and up to date blood glucose test. Following the assessment and discussion with the practice clinical team, the appropriate action was taken to ensure people were reviewed. We found people with acute exacerbations of asthma were not always followed-up in line with national guidelines to provide safe and effective care and treatment. For example, we found 28 people with asthma had received 2 or more courses of rescue steroids in the last 12 months. We reviewed a random sample of 5 records and found all five 5 patients had not been followed up in line with recommended guidance within 1 week of receiving steroid. We discussed the findings of the clinical searches with the practice team and following the assessment we received evidence to demonstrate that action had been taken to follow up on the people identified. Staff had the appropriate authorisations to administer medicines through Patient Group Directions or Patient Specific Directions.

There were systems and processes in place to enable information to be shared between the provider and services to ensure continuity of care. Regular meetings were held with multi-disciplinary teams to ensure care is co-ordinated effectively. The primary care network (PCN) helped to support the practice by providing links to pharmacists, mental health practitioners and social prescribers. People were able to receive co-ordinated care between the practice and the primary care network. Systems were in place to share information about patients electronically with other services. Clinical meetings were held every 2 months and practice meetings were in place to ensure all staff were kept up to date with guidance and best practice.

The National Patient Survey results demonstrated that 69% of people had enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses which was in line with local and national averages.

Processes were in place to support people to live healthier lives. There were flags on patients who were vulnerable and required ongoing monitoring and recalls in place to review patients and educate them to manage their health needs. There was regular engagement with community services and referral pathways in place. The practice website detailed information and links for health promotion, health conditions and common health questions.

We found that processes and systems were in place to recall and monitor patients with long term conditions and those who were prescribed high risk medicines and required regular monitoring. As part of the assessment we carried out remote clinical searches where we found some people required up to date monitoring. The findings of the clinical searches were discussed with the practice team and we received evidence following the assessment to demonstrate that action had been taken to review the patients identified. The practice had implemented a number of clinical audits to ensure the quality and safety of people’s care and treatment is effectively monitored and that the practice continuously improve their outcomes.

We found that clinicians understood the requirements of legislation and guidance when considering consent and decision making and saw that consent was documented.