Ferryview Health Centre 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 looked for evidence that staff involved people in decisions about their care and treatment and provided them with advice and support. At our last inspection in 2019, we rated this key question as requires improvement. At this assessment, the rating remains the same. We found the practice utilised local and national guidance to determine how patient needs should be assessed. However, this guidance was not consistently implemented.

This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were aware of how best to assess patients’ needs. Leaders told us that guidelines were in place, of which staff were aware. The practice utilised local and national guidance to determine how patient needs should be assessed. However, this guidance was not consistently implemented and utilised. For example, we reviewed 5 patients on the asthma register who had been prescribed 2 courses of rescue steroids in the past 12 months. National Institute for Health and Care Excellence (NICE) guidelines are that patients should be followed up within 48 hours of the prescription of rescue steroids, but this had not happened in any of the 5 cases that we reviewed. Therefore there was a risk that patients did not receive advice and treatment to help prevent future exacerbations. We reviewed 5 patients with hypothyroidism (condition whereby the body does not produce the right level of hormones), all of which were overdue monitoring tests. There was a risk these patients may be over or under treated for their hypothyroidism. Records that we reviewed showed that clinicians at the practice were involving patients in decisions relevant to their health, care and wellbeing. However, we saw that the details of the review were not thoroughly documented in 2 of the 5 patient care records we examined. There was a risk that information may not always be available to inform practice staff.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. The practice had clear protocols for the management of patients either through in-house, local or national guidance. However, our review of clinical records found care was not always provided in line with this guidance. For example, we found a number of patients were overdue monitoring tests, including patients with hypothyroidism, patients prescribed an immunosuppressant and patients prescribed a medicine to treat mood disorders.

Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. Care and treatment for patients in vulnerable circumstances was coordinated with other services. There were established pathways for staff to follow to ensure patients’ needs were met. The practice 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 practice supported patients to manage their health and wellbeing to maximise their independence, choice and control. The practice supported patients to live healthier lives and where possible, reduce their future needs for care and support. Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. There was a self-refer section on the practice’s website where patients could refer themselves without the need to see a GP. For example, for a weight management programme, stop smoking service and physiotherapy assessment.

The practice did not always routinely monitor patients care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of patients themselves. Leaders described how they monitored the uptake of patient monitoring for long term health conditions monthly at clinical meetings and compared their results with other practices in their commissioning area. They told us that the practice undertook audits and utilised the same clinical searches utilised by CQC in the assessment process to improve care for patients. Internal clinical searches completed by the practice failed to demonstrate how patients care and outcomes were promoted. The practice provided a number of completed audits completed by the practice prior to the assessment. However, only one of these audits had been repeated, and therefore could show improvement over a period of time. We also noted that although the practice utilised clinical searches to improve care, when CQC utilised the same searches, we found instances where safe and effective care was not being delivered. It was therefore unclear how the practice was effectively monitoring care to improve outcomes.

The provider told patients about their rights around consent and respected these when delivering person-centred care and treatment. Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.