Delapre 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 assessed all the quality statements for this key question. Our rating for this key question has improved from requires improvement to good. At this inspection we found improved systems to keep up to date with current evidence-based practices and to manage test results. There was evidence of clinicians’ training and supervision. Staff regularly reviewed the care being provided and worked with other services to achieve good outcomes. Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools. Feedback from patients was positive about the way staff treated people.

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 feedback we received from patients was limited regarding assessment of needs. However, the information we did receive was positive regarding patient’s needs being met. Results from the National GP Patient survey published in July 2024 showed 94% of respondents stated that during their last GP appointment they had confidence and trust in the healthcare professional they saw or spoke to.

The practice used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff checked people’s health, care, and wellbeing needs during health reviews.

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. 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. A remote review of the patient record system showed that patients received appropriate long-term condition reviews. Patients with long-term conditions were offered an effective annual review to check their health and medicines needs were being met. Our searches did identify a minority of patients who did not attend for regular reviews. We saw the practice made efforts to contact these patients. Evidence provided by the practice during the assessment showed further efforts had been made to engage with these patients. For patients with the most complex needs, the GPs worked with other health and care professionals to deliver a coordinated package of care. Registers were kept of patients with different health requirements. The practice identified patients with caring responsibilities and had signposting and policies in place to support their needs.

We could not collect specific evidence from patient feedback to score this evidence category. Our observations raised no concerns. The evidence we reviewed did not show any concerns about people’s experience regarding delivering evidence-based care and treatment.

Treatment templates were used that reflected current best practice guidance. Staff informed us they received updates on new guidance and when changes were required to patients care and treatment. Patients had access to appropriate health checks and assessments and were directed to relevant services when they needed extra support, such as those at risk of developing a long-term condition.

The practice had systems and processes to keep clinicians up to date with current evidence based practice. Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing. We carried out a remote search of the practice’s clinical records system to review if care and treatment was delivered in line with best practice. Our searches demonstrated, systems worked effectively to support safe and effective care for patients prescribed high-risk medicine or medicines that required regular monitoring.

Leaders within the practice had active roles within the local GP Alliance Federation and the Primary Care Network (PCN). The PCN employed staff such as physiotherapists, clinical pharmacists and health and well-being coaches that worked in the practice. There was schedule of regular meetings for different staff groups within the practice and minutes of meetings were available. Staff feedback was positive regarding teamwork and their involvement in making improvements to the practice. Registers were kept of vulnerable patients and those with complex needs. These patients were discussed at multi-disciplinary meetings with community staff to ensure their needs were being met.

Evidence demonstrated there were effective systems to share information between teams and services to ensure continuity of care, such as when clinical tasks were delegated or when people were referred between services. Registers were kept of vulnerable patients and those with complex needs. These patients were discussed at multi-disciplinary meetings with community staff to ensure they received appropriate support. These meetings were documented to ensure actions were completed as required.

We could not collect specific evidence from patient feedback to score this evidence category. The evidence we reviewed did not show any concerns about people’s experience regarding the practice supporting people to live healthier lives.

Staff encouraged and supported patients to be involved in monitoring and managing their own health. Patients had access to appropriate health assessments and checks. The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns and tackling obesity. However, the practice were below the national target of 80% for the uptake of cervical screening. We were informed the practice had taken steps to improve the uptake that included sending letters and making telephone calls to eligible patients who had not attended for screening, flags were placed on the patients’ clinical records to prompt staff to offer opportunistic appointments. Cervical screening appointments were available outside of normal working hours and with the extended hours service from 6pm to 9pm on weekdays. The practice were slightly below the minimum uptake target of 90% for 4 out 5 childhood immunisations. Parents or guardians were contacted following when children were not brought in for appointments. Appointments were available outside of normal school and work hours.

The practice had a social prescriber and health and well-being coach who meet with patients to maximise independence, lifestyle, and control. House bound patients were able to receive a home visit where appropriate. There were links to health information advice on the practice website. NHS and Carers Health Checks were available. Referrals were available to external organisations for healthy lifestyle support.

Staff and leaders demonstrated effective systems and processes to monitor and improve outcomes. Staff told us of incidents and complaints which had led to improvements from shared learning. Documentation was comprehensive and all staff had access to meeting minutes.

We found processes including those for complaints, incidents reporting and supervision were in place. There was documented evidence of shared learning throughout these systems. Clinical audits were undertaken by the practice that ensured best practice guidance was followed and that outcomes for patients were improved.

During our remote clinical searches we found patient’s treatment and care was monitored to ensure they received effective care. There was an evidence-based approach and appropriate documentation recorded when patients were reviewed by the practice.

We could not collect specific evidence from patient feedback to score this evidence category. Our observations raised no concerns. The evidence we reviewed did not show any concerns about people’s experience in relation to consent to care and treatment.

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. Staff understood the importance of ensuring that people fully understand what they were consenting to and the importance of obtaining consent before they delivered care or treatment. We saw that consent was documented.

Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision. Staff had received Mental Capacity Act training appropriate to their role.