Wordsworth Health 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 the practice had made improvements in the effective key question following the previous inspection in December 2022 to January 2023. We found the practice introduced an effective system in place to oversee regular staff training for clinical and non-clinical staff. There was evidence of formal clinical supervision for healthcare staff and patient needs were being appropriately met.

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.

We spoke to two patients from the Patient Participation Group. Both patients told us they felt clinical staff involved them in their care and treatments. Results from the GP national patient survey found 69% of patients stated that healthcare professional were good at listening to them, and 83% of patients stated they were involved as much as they wanted to be in decisions about their care and treatment. Eighty eight percent of respondents had confidence and trust in the health professional they saw or spoke to. The practice conducted an in-house survey which found, out of 489 respondents, 80% of patients felt healthcare professionals were either good or very good at listening to them, with 87% of patients agreeing they were involved as much as they wanted to be in decisions about their care and treatment. The in-house survey also found 76% of patients agreed the healthcare professional recognised or understood any mental health needs they had.

Leaders explained how people’s immediate and ongoing needs were fully assessed, and patients’ treatment was regularly reviewed and updated. Leaders told us they had systems in place to highlight specific patient requirements. For example, flags were used on the clinical record system to highlight any specific individual needs, such as the requirement to book double appointments or the need for a translator. Staff were aware of social prescribing schemes and referred patients accordingly to support them with their wellbeing and social needs. The practice told us they introduced an action plan to increase the number of patients performing cervical screening at the practice. This included providing allocated time for nurse clinicians to proactively call and emphasise the importance of cervical smears to younger patients, running a weekly report to see the performance uptake and having call-recall leads to monitor the cervical cancer screening programme. The practice organised a ‘women’s pink day’ in March 2024 to raise awareness of the importance of completing smear tests and child immunisations. During this event, staff spoke about the importance of cervical cancer screening and immunisations and clinical staff were present to conduct screening and immunisations. The practice told us they introduced an action plan to increase the number of childhood immunisations within the practice population. This included the development of educational materials to explain the importance of immunisations and a robust recall system for non-responders and non-attenders.

As part of the assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. A sample of the records of patients with long term health conditions were checked to ensure the required monitoring was taking place. A search for patients diagnosed with asthma who had 2 or more courses of steroids in the last 12 months, to check if they had been followed up correctly, identified 582 patients with asthma and 30 who had received 2 or more courses. We reviewed a sample of 3 cases and found all 3 patients had been appropriately followed up. We reviewed patients who were diagnosed with chronic kidney disease (CKD) stage 4 and 5 who have not had the required urea and electrolytes monitoring in the last 9 months. We reviewed a sample of 3 patients and found the patients were monitored appropriately but one patient was not correctly coded. We reviewed 3 patients with diabetes whose latest HbA1C was above 75mmol. We found, for one patient, a medication review was conducted but information on what was carried out during the medication review was not included.

Although we received no specific feedback from patients about evidence-based care and treatment, feedback from the 2024 Friends and Family Test and from the patients we spoke to on the phone was mainly positive.

Leaders told us the practice had systems and processes to keep clinicians up to date with current evidence-based practice. Staff had access and referred to the National Institute for Health and Care Excellence guidelines. Minutes from clinical governance meetings showed evidence-based guidelines and cases were discussed.

Staff discussed patients’ care and treatment at monthly clinical, safeguarding and multi-disciplinary meetings with minutes from meetings shared with clinical staff. A review of patients’ clinical records demonstrated they received evidence-based care. Leaders at the practice conducted regular supervision of clinical notes. The practice demonstrated evidence of clinical audits being used to monitor and improve outcomes.

We did not receive specific examples from patients about how staff, team and services worked together. However, the practice shared with us examples of how they worked effectively across teams and services to support people.

Leaders told us that when people received care from different teams and services, it was coordinated, and staff worked collaboratively to understand and meet the complexity of people’s needs. Leaders informed us discharge summaries from secondary care were coded and invites were subsequently sent to patients to be reviewed. Shared care agreements were made with secondary care providers regarding the prescribing and monitoring of patient medication. Leaders explained they met monthly with multi-disciplinary staff to discuss and improve outcomes for people with complex needs.

The practice worked with community care colleagues and had access to the rapid response service to conduct home visits if the practice had no capacity. The practice worked collaboratively with palliative care consultants to develop a tool to identify patients suitable for advanced care planning. The lead GP was awarded the 2024 GP of the Year by RCGP & Marie Curie Daffodil Standards for their work in apply end of life care quality improvement activity.

Staff had the information they needed to delivery safe care and treatment. There were systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment, such as care plans through Coordinator My Care. Staff regularly liaised with community teams such as health visitors. There were appropriate referral pathways to ensure patients’ needs were addressed. We reviewed a sample of shared care agreements and found no concerns. Referrals were documented with a system in place to ensure monitor delays.

During this assessment, we spoke to two patients over the phone who told us they were encouraged to live a healthier lifestyle. For example, the practice conducted a ‘chair-based exercise’ with patients on a weekly basis. This was aimed at people with long-term physical conditions and older/isolated people who no longer took part in traditional exercise. Data collected by the practice showed 601 patients took part in the chair-based exercises between January-July 2024. Feedback collected from patients on the chair-based exercise were positive.

The practice identified patients who needed extra support and directed them to relevant services. For example, a social prescriber worked with the practice three times a week and assisted patients in leading healthier lives.

Staff encouraged and supported patients to be involved in monitoring and managing their own health. We reviewed consultation notes and medication reviews and saw appropriate care and treatment was given with patient’s immediate and ongoing needs fully assessed.

We did not receive specific examples from people about monitoring and improving outcomes.

Leaders described how they met regularly to monitor the progress and outcomes of patients. Audits were discussed at clinical meetings and were used to link to areas where they felt quality could be improved, such as the management of diabetes and use of high-risk drugs.

The practice submitted clinical and management audits which were carried out to improve outcomes for patients. Clinical audits included quality improvement programmes into the use of teratogenic drugs, the use of high-risk medicine, end-of-life care and diabetes. Management audits included human resources compliance audit and a staff immunisation compliance audit.

Verified data showed that 53.5% of eligible patients at the practice were screened for cervical screening adequately between March 2023 to June 2023, falling below the 80% World Health Organisation target. The practice showed unverified data that they had screened 89% of eligible patients for those aged 25-49 in the last 3 and a half years and 84% of eligible patients for those aged 50-64 in the last 5 and a half years. Verified data showed the practice were below their targets for childhood immunisation targets; 75.7% of children aged 5 received immunisation for two doses of MMR, 86.6% of eligible children completing a course of immunisation for hepatitis B, 67.9% of eligible children received their immunisation for pneumococcal infection, 69.6% of eligible children received their immunisation for Meningitis C and 75% of eligible children who received immunisation for one dose of MMR. The practice showed unverified data had received 80% and above for 2 out the 3 indicators for childhood immunisations in 2024 and 70% for children vaccinated with two doses of MMR. In the last inspection, the practice could not demonstrate they had a failsafe system for two-week wait referrals. The practices’ policy on managing two-week wait referrals had been revised and a review of their failsafe log demonstrated they were following their processes.

During this assessment we spoke to two patients form the Patient Participation Group. We had no concerns on their rights around consent.

When reviewing patient records, we saw that consent was documented. Clinicians and non-clinicians we spoke to understood the requirements of legislation and guidance when considering consent and decision making. Where appropriate, clinicians were able to assess and record a patient’s mental capacity to make a decision.

We reviewed the Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions of three patients and found decisions were made in line with relevant legislation with appropriate consent obtained.