The Limes Medical Centre

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 found patients care and treatment was not always provided in line with evidence-based guidance, and we identified concerns in the care of patients’ health conditions. At this assessment, we found patients with long term conditions needed improved monitoring, patients’ needs were not always assessed in a timely way, and care and treatment was not always delivered in line with current legislation, standards and evidence-based guidelines. There was limited clinical leadership and oversight, and staff feedback demonstrated clear issues with the culture in the practice which could impact in providing effective care to patients.

This service scored 50 (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 patient survey results demonstrated that 88% of patients felt their needs were met during their last general practice appointment which was in line with local averages and just below national averages. However, the shortfalls we identified in relation to this could impact people’s care. You can find more details of our concerns in the evidence category findings.

There were referral pathways in place to make sure that patients’ needs were addressed, however these needed strengthening to ensure they were routinely followed. For example, staff were able to tell us the system in place for making two week wait referrals but was unable to describe the process for monitoring and following these up. We found that clinicians were working in silos and were responsible for their own patient lists. We were unable to gain assurances that processes were effective for all patients registered within the practice. Staff we spoke to were aware of the workflow, however we found limited evidence to demonstrate how the practice provided further education and support to patients as there had only been 1 practice meeting in the last 6 months. We found that staff had the skills to carry out reviews where appropriate, but some staff reported being allocated patients that were outside of their competencies and that GP’s refused to carry out home visits for patients. In addition, staff told us some GPs refused to sign prescriptions for patients if they were not their named GP which often led to delays in patients receiving their prescription.

We found there was a lack of systems and processes in place to ensure the safe, care and treatment of patients. We found there were backlogs in monitoring patients with long term conditions and carrying out learning disability and mental health reviews. There was a lack of consistency in working practices amongst clinicians that was not always within current evidence-based practice. During the remote clinical review, we found medicines management did not always reflect current and relevant best practice and patients care needs were not always reviewed.

Leaders told us they had systems in place, however we found that systems did not always ensure effective monitoring of patients care and treatment. We found long term condition monitoring required strengthening to ensure patients were monitored effectively. For example: Clinical searches suggested 24 patients had results which showed they had a new diagnosis of diabetes but had not been coded appropriately and no action had been taken to inform the patients of their diagnosis or arranged for monitoring of their condition. We sampled 5 patients prescribed methotrexate and found they were overdue blood tests. There was no documentation in the patient records that blood results taken in secondary care were being reviewed before a prescription was issued as this was not documented within the patient records. Staff told us there was no formal supervision in place to monitor prescribing of medicines and they were not supported by leaders in delivering high quality care.

We found people with long-term conditions were not always 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 not in line with National Institute for Health and Care Excellence (NICE) recommendations. For example: Clinical searches suggested that 32 patients with a diagnosis of hypothyroidism were not being monitored appropriately. We sampled 2 clinical records and found they were overdue monitoring, but medicines were still being prescribed without reviews having taken place. We found that there was no effective approach to delivering and monitoring care. We found inconsistencies in assessing patients’ immediate and ongoing needs including their clinical needs and their mental and physical wellbeing and we were provided with limited assurance that patients presenting with symptoms which could indicate serious illness were followed up in a timely and appropriate way.

Minutes of meetings were provided, these included safeguarding and palliative care meetings. Staff told us that there had been 1 practice meeting in the last 6 months and not all staff were able to attend. Nurses told us they had their catch-up meetings to address any issues. Leaders told us they regularly attended primary care network (PCN) meetings, but we were provided with no evidence of this during our assessment. We found on speaking to a range of staff that there was a clear lack of communication within the practice with staff being unable to approach leaders and discuss people's care and treatment without fear of retribution or a lack of confidence issues would be addressed. We were told that information was usually cascaded via email.

There were some processes in place for working with agencies to manage care. For example, safeguarding meetings were regularly held. We found evidence that palliative patients were reviewed internally every 6 weeks, however there was no evidence of regular staff meetings to ensure all staff were kept up to date with guidance and best practice. Systems were in place to share information about patients electronically with other services, however we found a limited approach to collaborating and coordinating patient care internally within the practice.

Due to difficulties in the lack of systems and processes we found some delays in carrying out annual reviews for patients. and were not fully assured that the practice was identifying patients who may need extra support and directed them to relevant services. This included patients at risk of developing a long-term condition, carers and those with a learning disability. We were told that there was no overall lead in managing recalls and this was managed between clinical and non-clinical staff, we were therefore not assured that patients had access to appropriate health assessments and checks.

There were flags on patients records who were vulnerable and required ongoing monitoring, however the recall system needed strengthening to ensure all people with complex health needs and long-term conditions were regularly reviewed and received support to manage their health needs. We found a lack of clinical oversight to ensure systems were effective to enable patients to be monitored and supported to live healthier lives where possible. The practice website detailed information and links for health promotion, health conditions and common health questions.

We found inconsistent approaches to monitoring peoples care and treatment and found during the remote clinical review not all patients had received an annual review and were not being appropriately monitored to ensure their high-risk medicines and long-term conditions were regularly reviewed. For example, we found patients were identified who had a potential missed diagnosis of diabetes. Patients with hypothyroidism did not routinely have regular thyroid function tests. Patients with asthma who had been prescribed 2 or more doses of steroid medication in 12 months were not issued with steroid warning cards. During this assessment we told to take action to review patients that required immediate action.

We found that processes required action as there was a lack of systems to recall and monitor patients with long term conditions and those who were prescribed high risk medicines and required regular monitoring. We found no evidence to demonstrate that the practice had a programme of targeted quality improvement and monitoring and used information about care and treatment to make improvements.

We found the practice systems were not sufficient to ensure that those patients requiring medicine reviews and ongoing monitoring were actively being reviewed and recalled. There were limited systems in place to identify and manage patients who required monitoring. Our clinical searches showed systems were ineffective to ensure patients were safely monitored. The overall trend for child immunisation was below 90% for 4 out of 5 indicators and cervical screening was significantly below the 80% target. Although the leadership team attributed some of the under achievement in difficulties with their patient population, we found these outcomes had declined further in the last 2 years and there was no plan in place to address this.

Staff were able to tell us the process they followed when obtaining consent. For example, when carrying out examinations and minor surgery procedures. However, we found that the practice did not always obtain consent to care and treatment in line with legislation and guidance. For example, we found issues with 3 out of 5 Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions.

We found that our clinical searches found 3 out of the 5 records viewed showed that the documentation for a DNACPR was not completed thoroughly or signed by an appropriate clinician. We found there were gaps in staff’s training on mental capacity and could not be assured they understood legislation when considering consent and decision making.