Abbey Field 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 4 quality statements from this key question. We have combined the scores for this area with scores based on the rating from the last inspection, which was good. Our rating for this key question remains good. At this assessment we found people’s 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. Staff regularly reviewed people’s care and treatment. Staff, teams and services worked together to improve people’s outcomes and support people whose circumstances may make them vulnerable. People’s consent was sought appropriately.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Feedback from the friends and family test and feedback collected by CQC, was mostly positive and included comments about people’s assessment and review of their care and treatment. People were involved in any assessment of their needs, which included their carers, as appropriate. Some care home staff received weekly calls and visits for people to be assessed, which they reported worked well.

Leaders and staff told us systems and processes were in place to identify people’s needs and preferences during the registration process. Reception staff 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. Leaders and staff told us information on digital flags were used to tailor their approach to meet people’s needs. Leaders and staff told us they prioritised people who were clinically vulnerable to ensure their needs were assessed and any immediate care and treatment was delivered. Staff told us, and we saw evidence in clinical records, of clear documentation to support clinicians’ decision making. People were made aware of seeking further help if their condition deteriorated. Staff checked people’s health, care, and wellbeing needs during health assessments and reviews. Staff actively referred people to social prescribing to support with their wellbeing and social issues.

The systems in place ensured people’s assessments were up-to-date and staff understood their current needs. There were appropriate referral pathways to make sure people’s needs were further assessed and addressed. The practice had systems to identify and prioritise assessment, care and treatment for its most vulnerable people. For example, we saw that all people with a learning disability were offered an annual health assessment, and reasonable adjustments were considered to support their attendance at these appointments. Weekly visits and telephone calls were made to people who lived in care homes who needed to be assessed. The practice had a system in place to identify people with caring responsibilities and held a carers’ register. The practice had 4.8% of their population registered as carers. The practice worked closely with their GP care advisor and social prescribers to assist people to access support from the practice and additional support within the local community.

Feedback from the friends and family test and feedback from people collected by CQC, was mostly positive and included comments about the knowledge of clinical staff and how people were involved in their care and treatment. People were generally happy with the care and treatment they received. A care home representative gave an example of how they worked in partnership with practice clinicians to ensure effective care for a person they supported.

Leaders and staff told us they worked to current National Institute for Health and Care Excellence (NICE) guidance and local clinical protocols. Staff told us that the leaders provided opportunities for them to keep up to date with current guidance and changes to evidence-based care and treatment. Staff told us they were able to attend meetings to discuss cases and new guidelines, and minutes of the meetings were taken and shared with staff. Staff told us they were supported to attend training to keep updated and further develop their knowledge and skills.

The practice had systems and processes to keep clinicians up to date with and to monitor their use of current evidence-based practice. The minutes of clinical meetings were taken and shared with staff. The practice systems identified people with a range of long-term conditions and undertook a full assessment of their physical, mental and social needs as part of their review. People with multiple long-term conditions were reviewed during 1 longer appointment where possible. Arrangements were in place to coordinate any tests required, so results were available at the time of the review appointment. There were processes in place to follow up people who did not attend for their review. Staff carrying out long-term condition reviews had received appropriate training for this role. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. People with poor mental health, including dementia, were referred to appropriate services. Systems were in place to follow up people who had received treatment in hospital or through out of hours services. The practice monitored and improved outcomes for people by carrying out clinical audits. We observed from the clinical searches we carried out that the service delivered evidence-based care. The practice demonstrated that they had a system to identify and follow up people who may have a potential missed diagnosis of diabetes and people with diabetes were monitored and reviewed effectively. People with chronic kidney disease stages 4 or 5 were monitored appropriately.

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.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

People told us they were happy with their care and treatment and those who had a long-term condition told us they were reviewed. The practice collected feedback from people who had undergone a coil insertion or minor surgical procedure. People reported they had been made to feel welcome, had been given sufficient information and time to discuss the procedure, did not experience discomfort and were happy with the outcome.

Feedback received from staff and leaders was positive about monitoring and improving outcomes. Leaders and staff told us they met regularly to monitor progress, for example with the completion of learning disability heath assessments. Work was planned, which included the resource needed, to meet people’s needs, for example additional nurse resource for cervical screening being available on Saturdays. Leaders and staff explained to us that their practice population included people of different cultures and who spoke different languages, and it could be difficult at times to engage people to attend, for example, for cervical screening and childhood immunisations.

Clinical searches showed effective care and appropriate monitoring of people with long term conditions. There was a structured systems in place for inviting people in for their long-term condition annual reviews and there were designated administration staff who had oversight of this. Arrangements were in place to follow up people who had not attended. Regular audits of these processes were completed, to ensure they were effective. The provider monitored and improved clinical outcomes for people by carrying out repeated cycle clinical audits. Processes were in place to monitor, review and act on the friends and family test feedback on a monthly basis and we saw records from July 2017 to June 24. All comments were reviewed, and where possible, actions were taken in response to feedback, and monitored to ensure they had a positive impact on people’s outcomes.

91% of people with a learning disability aged 14 and over had received a learning disability health check in 2023 to 2024. 42% had already received a health check since April 2024. 81% of people with a severe mental illness had received a health check in 2023 to 2024. 37% had already received a health check since April 2024. Arrangements were in place to invite and complete NHS health checks for people who were eligible. 26% of NHS health checks had been completed for people who were eligible since April 2024. We discussed the practice performance in relation to childhood immunisation and cervical screening. The practice monitored and regularly reviewed uptake and additional appointments were made available for cervical screening when needed, for example during Saturday clinics. Arrangements were in place for following up people when they did not respond to invitations or missed appointments. People could book appointments to discuss with a clinician any concerns they had about childhood immunisation and cervical screening. For missed childhood immunisation appointments, when necessary, the practice would liaise with other agencies including health visitors and consult their safeguarding procedures if required. The practice worked with a range of other organisations to further support and encourage the uptake of cervical screening and information was available to encourage uptake.

Feedback from the friends and family test and feedback collected by CQC, was mostly positive. People gave examples of how they felt at ease during consultations, were listened to and how examinations were explained well. People were appropriately informed when making care and treatment decisions. We received feedback from a care home representative regarding a person who had a blood test successfully at the practice, following appropriate preparation from carers and liaison with practice staff. People’s carers were satisfied with the knowledge practice staff had of the Mental Capacity Act.

Clinicians told us they supported people to make decisions, and where appropriate, they assessed and recorded a person’s mental capacity to make a decision. Clinicians told us they always obtained consent from people and offered a chaperone where appropriate, which was recorded on the clinical system. They told us for some procedures written consent was discussed with and obtained from people before a procedure was undertaken. Staff had a good understanding of consent and had received Mental Capacity Act training.

People were offered a chaperone when carrying out examinations, we saw posters displayed in the practice informing people this service was available. Staff who carried out chaperone duties were trained for the role and had received a disclosure and barring (DBS) check. The practice had systems and processes in place to obtain consent to care and treatment in line with legislation and guidance.