Solent GP Surgery

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 assessed all quality statements under the Effective key question. We found staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this. In this assessment we found that Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms were completed in line with national guidance and the Mental Capacity Act 2005.

In addition to this, we saw examples of innovative work. For example, the practice had completed a review of their diabetic service, which had led to the implementation of a multidisciplinary approach to care for patients diagnosed with diabetes. Furthermore, the practice had a systematic approach to quality and improving patient outcomes. This was demonstrated in community joint nurse clinics and the implementation of integrated neighbourhood teams.

However, childhood immunisations uptake data and cervical screening rates remained below national targets. The practice was already working to improve uptake, for example by developing close working relationships with community centres and schools. Our review of the clinical searches of patient records showed patients were being effectively managed.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area.

We spoke with members of the management team who explained how patients requiring monitoring were supported and managed. This included inviting them for annual health reviews and monitoring checks.

Clinical staff we spoke to were able to demonstrate how the practice provided further education to assist young families in the importance of vaccinations. Staff had the appropriate skills and training to carry out reviews for this demographic.

Staff we spoke to were aware of proactive initiatives such as patient engagement and educational leaflets and website information to improve cervical screening uptake for eligible patients.

Patients’ accessibility and communication needs were recorded, and they were supported accordingly. There was a care navigation process in place and staff received training for this. The practice had a palliative care register and these patients were reviewed in monthly multi-disciplinary meetings. A review of clinical records showed that generally patients were effectively managed by the practice. This included the management of patients with long-term conditions including asthma, chronic kidney disease, diabetes retinopathy and hypothyroidism.

Staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. Staff could refer people with a range of needs, such as those experiencing social isolation, into neighbourhood support groups via a well-established team of social prescribers based within the practice. The practice had developed health literacy videos to support patients with a learning disability. The practice also demonstrated the use of reasonable adjustments by offering home visits to those who are carers as part of a wider carers project.

The practice was involved in a pilot project of CARDMEDIC, which helped patients whose first language was not English to communicate with the reception team.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area.

Clinical staff told us they followed best practice guidance when carrying out their work. They also told us they had access to training and learning opportunities and were supported with their professional development.

Staff told us the practice carried out clinical audits to compliment quality improvement, such as the routine review of clinicians’ prescribing data to ensure care was provided in line with national guidelines and to provide feedback during staff appraisal processes.

The practice had systems and processes in place to keep clinical staff up to date with current evidence-based practice. Our review of the clinical searches of patient records showed patients were being effectively managed in relation to their long-term conditions. This included monitoring requirements in line with national guidelines.

The practice were involved in National improvement work for patients with chronic obstructive pulmonary disease (COPD). This was through the development of new approaches to planning and delivering patient care, such as utilising digital platforms in collaboration with secondary care services to empower patients to make choices about their care and treatment based on current good practice.

All staff and leaders were encouraged to keep up to date with research. For example, a practice GP worked with the wider Trust research team to ensure primary care was involved in upcoming research projects.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area.

Staff and leaders told us about services they worked closely with. This included a variety of local organisations, including those in the voluntary, community and social enterprise sector.

Staff told us they had access to the information they need to appropriately assess, plan and deliver people’s care, treatment and support. In particular, people transitioning between services. Staff told us they had enough information to plan and refer people and received subsequent results and information about people following referral.

Practice staff told us they routinely shared information with other teams and services, and this included any reasonable adjustments that patients required. External professionals were invited to relevant meetings. We were told where they did not attend, meeting minutes were not routinely shared with them, but any relevant information was relayed to them.

Leaders told us practice communication such as service updates and pathways with local care providers were sent to staff via email.

The practice was able to demonstrate views from staff and people were listened to and acted upon, such as actions taken in response to feedback from people. For example, feedback from people who used the service stated that relevant staff and teams were involved in planning and delivering people's care and treatment. Staff told us they worked collaboratively to understand and meet people's needs. We saw evidence of this through the review of surveys about preferences of accessing care and how continuity was managed between staff.

We spoke with the local Integrated Care Board ahead of this assessment. From the feedback we received from them there was no indication of concern in this area.

We saw examples during our review of the practice’s clinical records systems that plans for transition, referral and discharge did consider people’s individual needs, circumstances, ongoing care arrangements and expected outcomes.

The practice had developed multidisciplinary team meetings to discuss vulnerable patients who required care and treatment from different types of services working together. There was a collaborative approach to planning and coordinating patients care and treatment with external teams at the earliest possible stage. Leaders had developed the Collaborative Innovation (COLIN) group which had inspired a culture of improvement in all staff. Staff told us that the group enabled them to review practice needs, understand current outcomes and explore best practice to ensure learning was widely shared and acted on.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area.

Staff told us about the ways in which they supported patients to manage their health and wellbeing, and to live healthier lives. This included referral to a team of social prescribers and encouraging patients to attend health checks and reviews. Staff were aware the uptake rates for childhood immunisations and cervical screening were lower than local and national averages and were taking steps to improve this. For example, staff were working closely with partners in local voluntary, community and social enterprise organisations who were well placed to relay health information to their populations.

People were involved in regularly monitoring their health, including health assessments and checks where appropriate and necessary with health and care professionals. We saw examples of healthcare initiatives to support the practice population including mental health projects with the community hub and local school education sessions for children regarding health and wellbeing.

The practice worked closely with external stakeholders such as Working Education Association, which provided education for health provision and promotion for refugees and people in the community who were new to the country.

Further to this, the practice was involved in the development of Integrated Neighbourhood Team working, and had a particular focus on personalised care and fraity. This involved multidisciplinary team working with community and statutory organisations to develop prevention opportunities for patients identified with mild to moderate frailty.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area.

Staff we spoke with could clearly outline the systems in place to recall and review patients and understood their role in this process. They told us how they took a proactive approach to encourage patients to attend for cervical screening and childhood immunisations, for example through the use of a family worker who promoted services within nurseries and external events.

Our review of patient clinical records showed the practice worked with patients to monitor and improve outcomes. This included the management of patients with long-term conditions. The practice worked with other organisations within their local community to promote best practice in health and care. Appropriate registers were held and regularly reviewed to ensure effective monitoring of specific groups such as those receiving palliative care. The practice worked with the local cancer care alliance and voluntary, community and social enterprise sector to ensure services were accessible to patients with diverse cultural and socioeconomic needs.

The practice had carried out quarterly cancer care reviews with patients via telephone and face to face appointments. People received further support and information packs were shared by the practice at point of registering, which included an invitation to discuss care needs, mental health support such as counselling, signposting to hospice care and referral links with the social prescribing team.

People with long-term conditions received regular management plans and reviews with reasonable adjustments including extended appointments to discuss care and treatment.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area.

Staff told us how they obtained consent and how they helped patients make decisions about their care, including the use of relevant guidelines and recording consent.

There was a consent policy in place which covered areas such as capacity, children’s consent and recording decisions. Carers and advocates were involved in consultation processes where required, and resources were used to support patient’s understanding of their treatment. The practice actively ensured that language was not a barrier to the consent process, via the use of translation, CARDMEDIC and ensuring that patient records held accurate communication needs.