Salisbury Avenue Healthcare

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

Patients' needs were assessed, and care and treatment were delivered in accordance with current legislation, standards, and evidence-based guidance supported by clear pathways and tools. Patients' feedback was mainly positive about the way staff treated people.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us that they felt involved in decisions about their care, that they could ask questions during their consultation, and that they received an explanation in a way that they understood.

Leaders and staff told us they add alerts to patient records to highlight people’s communication needs and any impairments. The service had access to interpreter services, and the administration staff we spoke with told us that they would support patients with communication needs. For example, some patients communicated via text as they could not communicate at the desk.

The practice had systems and processes to identify people’s needs and preferences during registration. Staff actively referred patients to social prescribing to support their well-being and social issues. The practice also had a system to identify people with caring responsibilities. Clinical searches were positive and showed good care and appropriate monitoring of patients with long-term conditions and those on high-risk medicines. There was a structured system for inviting patients in for their long-term condition annual reviews. However, medication reviews needed to detail what the clinician reviewed.

People told us they were happy with the care and treatment they received. Results from the practice’s internal patient survey confirmed these findings.

During the inspection, we identified 112 unactioned patient test results. In response, the provider confirmed that urgent abnormal results are accompanied by a lab phone call to the practice, to ensure immediate action. None of the 112 fell into this category. The provider told us there was an administrative error that led to the results not being re-assigned to one of the two GPs scheduled to review the results. Following the inspection, the provider discussed the incident during a team meeting and introduced an additional safety measure; the daily duty doctor will also have an end-of-day blocked slot for lab result checks to act as a second pair of eyes in case such a situation should arise again. 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. Patients were encouraged to be involved in monitoring and managing their own health and were referred to additional services if needed. GPs told us they worked with current NICE guidance and local clinical protocols.

We undertook a series of searches on the practice’s clinical records system to review whether care and treatment were delivered in accordance with best practices. Systems worked effectively to support safe and effective care for patients prescribed high-risk medicine or medicines that required regular monitoring. Our searches did identify nine patients who were overdue reviews. However, we saw evidence that the practice repeatedly attempted to contact these patients.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

The patients we spoke to told us clinicians supported them to live healthier lives. For example, one patient told us clinicians spoke about their life choices and healthy eating.

Staff and leaders told us they included and encouraged patients to participate actively in their health and well-being. Staff could signpost patients who required social support via a care coordinator who visited the practice one day a week and a social prescribing app. The practice did not have a social prescriber. The provider told us they had requested one from the Primary Care Network (PCN).

The practice had embedded recall systems to support patients in managing their health. During our clinical searches, we found patients had received medication medicine reviews promptly. The practice staff were knowledgeable and referred to specialist services when appropriate.

Patients said they were satisfied with their care and treatment, and the practice invited them for an annual health check, blood tests and medication reviews.

Staff carrying out long-term condition reviews had received appropriate training for the role. Staff and leaders demonstrated effective systems and processes to monitor and improve outcomes. Staff told us of incidents and complaints that led to improvements from shared learning. Documentation was informative, and all staff had access to meeting minutes.

We found robust processes, including those for complaints, incident reporting, and supervision. We found documented evidence of shared learning throughout these systems, which improved patient outcomes. We reviewed two clinical audits carried out by the practice, the details of which are below. Direct oral anticoagulants (DOAC) audit: August 2021 – 45% of patients identified as not having their blood test done. Fifty-five percentage were identified as not having an up-to-date weight measurement. July 2023 – 96% of patients had their renal function tested within the recommended time; this is an increase from 51% at last audit. Eighty-five percent of patients had their weight measurement done within the time frame, an increase of 30% from the last audit. Further to this 92% of patients had both a weight measurement and blood test done within the last year; an increase of 66% from last audit. Four percent of the total amount of patients required up to date blood tests which have all been requested; a decrease from 45% at last audit. The practice also conducted an amoxicillin audit, which identified the number of prescriptions not compliant with local guidelines. The audit showed that the practice was significantly below local GP practices for its prescribing of amoxicillin and antibiotics overall.

During our clinical searches, we found that patients' treatment and care were monitored to ensure they received effective care. However, patient reviews required more detail. Following the factual accuracy process (the checking process allows providers to tell us where information is factually incorrect and where our evidence in the report may be incomplete), the provider submitted additional information, which evidenced that clinical staff documented protocol to follow for repeat medication reviews. Additionally, since the inspection, clinical staff have been reminded to not only evidence a medication review has taken place, but also to summarise the steps they took per the practice protocol.

Patients told us clinicians requested consent to deliver care and treatment when required.

Staff understood consent well and received appropriate safeguarding training, including the Mental Capacity Act and Deprivation of Liberties training.

We saw that clinicians documented consent appropriately. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were made in line with relevant legislation and were appropriate.