Alrewas 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

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity.

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 people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Staff were aware of the needs of the local community. The provider 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. Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to their Care Co-ordinator or to the Primary Network social prescriber.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. The number of patients identified by our clinical searches as having a potential missed diagnosis of diabetes was 6 patients out of 7,467 on the practice register. We sampled 5 patients records. Of the 5 patients, 1 had a delay in their repeat interval monitoring, another patient was advised to have a repeat test and failed to book. Following our feedback the practice actions included a recall and review of these patients. The long-term conditions medicines monitoring recall system was based on the patients birth month. Our clinical searches showed the potential for overdue monitoring in 25 out of 815 patients, on medicines used in the treatment of high blood pressure. We sampled 5 records, 1 patient was new to the practice, another appeared to not comply with requests for monitoring, another was under the care of secondary care and 2 had been sent reminders for monitoring.

We found that the results from completed monitoring held in electronic systems with the pathology were not always downloaded or documented in the clinical records. There were 301 hypothyroid patients on the practice register. Of these 10 patients appeared overdue monitoring. We sampled 5 records and found monitoring was overdue. It was evident however that the practice had sent reminders to patients, but they had not attended. The provider following this feedback described the actions they would take to encourage attendance which included replacing repeat medicine prescribing to acute prescribing measures until monitoring had taken place.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services. Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

Staff focused 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. As a member of the Primary Care Network, patients had access to NHS Health checks for those aged 40-74 via the ‘Everyone’s Health’ initiative which had been readily taken up by patients. The practice had a designated staff member appointed as the ‘Active Practice Champion’ who encouraged patients and staff alike to become involved in Park Runs. The practice was an armed forces veteran friendly accredited GP practice, with access to appointments, appointment timings and referrals considered as part of the practice support for veterans.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people. The practice completed quality improvement and clinical audits, these included for example, minor surgery, prescribing, clinical register reviews and shared care medicine audits. The practice met national targets for screening and immunisations. From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. We sampled 6 out of the 34 patient records with a Do not attempt cardiopulmonary resuscitation (DNACPR) decision. Of these, 3 contained the majority of the information expected, however 3 appeared to need further consideration. The provider told us they would consider our feedback in respect of the information contained on the patients electronic record regarding their Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms. These tools offer patients the opportunity to plan their future care and support. This includes medical treatment and resuscitation options, while they have the capacity to do so. Patient preferences and clinical recommendations were recorded on the non-legally binding form. The form could be reviewed and adapted if circumstances change. There should be clear notes in the patient's records about the DNACPR discussion and the reasons. DNACPR decisions are communicated to everyone involved in the patient's care, such as their GP, care home staff and the nursing team .