Goodcare Practice

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 reviewed 6 quality statements in the Effective key question – 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 and consent to care and treatment. Patients were regularly assessed, and care and treatment were delivered in line with current legislation and evidence-based guidelines. The service had a programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. Staff worked together and with other organisations to deliver care and treatment.

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.

No concerns were raised by those using the service about the delivery of evidence-based care and treatment.

Leaders explained how patients’ immediate and ongoing needs were fully assessed, and patients’ treatment was regularly reviewed and updated. Leaders and staff told us the service would use a series of codes and alerts on the patient record to highlight people’s communication needs and any impairments. The service had systems and processes in place to identify people’s needs and preferences during the registration process. Staff told us they checked people’s health, care, wellbeing and communication needs during health reviews.

We also saw that the practice had set up systems so that patients could have all their appointments scheduled and booked in one go; for example, patients could be booked in to see the nurse and GP and pharmacist in the same visit. One of the partners was the lead for diabetes, they had done a lot of work with diabetic patients within the practice. As a result patients’ diabetic management had improved and the practice was asked by the Ealing borough’s lead diabetes GP to share their knowledge and experience

We saw patients’ medicines were appropriately prescribed in line with the relevant legislation, current national guidance, or best available evidence.

Our clinical record searches found safe management and monitoring of high-risk medicines and people with long-term conditions.

We undertook a review of patient records at the service and found that guidelines were being followed patients’ immediate and ongoing needs were fully assessed.

No concerns were raised by those using the service about the delivery of evidence-based care and treatment.

Leaders and staff told us the service had systems and processes to keep clinicians up to date with current evidence-based guidelines. Staff feedback they received regular updates from leaders at the service for example during clinical, monthly practice meeting, education sessions for clinical staff. Where there were changes in process guided by learning at the service, staff told us that they were informed and involved in implementing changes.

The service delivered people’s care and treatment in line with current national guidance and best practice. Staff discussed patient care at clinical, safeguarding and integrated care team meetings. A review of a sample of patients’ clinical records demonstrated they had received evidence-based care. Staff had completed clinical audits to ensure they were meeting clinical guidelines. The GP partners monitored the services clinical performance.

There were effective arrangements in place for working with other health professionals to ensure quality of care for patients. During this assessment we were able to speak with two patients. They told us clinicians took time to explain things and helped them to understand any issues they had.

The leaders explained that when people received care from a range of different staff, teams or services, it was coordinated, and staff worked collaboratively to understand and meet the range of different people's needs. For example leaders told us that, in September 2024, they engaged with the services of a diabetic specialist pharmacist who conducted reviews and optimized medications for patients with Type 2 diabetes on oral treatment to help reduce cardiorenal risk. They also set up COPD clinics from September to November 2024 which was led by a respiratory specialist nurse. COPD patients were scheduled for face-to-face appointments, each lasting 30 minutes. During these appointments, annual COPD reviews were done, and they assessed inhaler techniques as part of their quality assurance activities aimed at reducing exacerbations in COPD patients.

The service ensured that care was delivered in a coordinated way and took into account the needs of different patients, including those who may be vulnerable because of their circumstances. There were clear and effective arrangements for booking appointments and transfers to other services.

The service ensured that care was delivered in a coordinated way and took into account the needs of different patients, including those who may be vulnerable because of their circumstances. There were clear and effective arrangements for booking appointments and transfers to other services

No concerns were raised by those using the service about supporting people to live healthier lives.

Leaders told us they were working with the Patient Participation Group (PPG) and had set up a weekly exercise programme, where female patients were welcome to attend and participate in social therapeutic exercise. Staff told us they worked alongside care coordinators and social prescribers and could refer patients to them for advice and support.

The service had referral pathways to help patients live healthier lives, for example smoking cessation. The service also had a social prescriber in place to meet patients’ other social needs.

No concerns were raised by those using the service about monitoring and improving outcomes.

Leaders described how they monitored the uptake of patient monitoring for long term health conditions during clinical meetings and compared their results with other practices in their primary care network. Leaders and staff told us that audits were discussed at clinical meetings; this was confirmed in the minutes of the meetings we reviewed.

The practice submitted a range of clinical audits which demonstrated quality improvement. Leaders held monthly quality meetings which monitored patients’ outcomes, where the findings were shared with the local integrated care system.

The provider performed below the national target for 4 indicators relating to childhood immunisations and cervical screening. The practice was aware of this and had already invited an immunisation nurse from the Integrated Care Board (ICB) to help them improve vaccination uptake. The practice informed us they were actively call-and-recalling patients, they offered a range of appointments, if patients declined the nurse would follow up with a phone call. If patients still refused, the GPs would reach out and discuss the importance of immunisations.

No concerns were raised by those using the service about consent to care and treatment.

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. 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.

We saw a copy of the consent policy. We reviewed five patients’ Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions and found they were made in line with relevant legislation and were appropriate. Most staff had completed mental capacity act training.