Abbamoor Surgery

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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 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. People’s immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing. Our review of the remote searches of patient records showed that care and treatment was evidence-based and in line with good practice standards. Staff were up to date with national legislation, evidence-based good practice and required standards. During the assessment treatment was seen to be effective and the practice responded and acted on the comments made by the GP specialist advisor following the remote clinical searches to improve processes and procedures. Communication needs of patients were considered, and we saw that the practice could support patients with translation requirements, hearing or visual disabilities. The needs for carers of patients were also considered. Staff were able to use a social prescriber to support and sign post patients and carers to additional support.

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.

During our assessment, people we spoke with told us they were involved in their care and treatments, and that the staff supported them with decision processes. We were told by people they received appropriate referrals for ongoing care and treatment. Carers told us the practice supported them and ensured their health needs were assessed and met. People said they were told to seek further help should their condition deteriorate. Results from the national patient survey were positive. Patient feedback from the national patient survey showed that 96.3% of patients said last time they had a general practice appointment; the healthcare professional was good or very good at treating them with care and concern. The national average was 84%. The national patient survey showed that 99% of patients said the healthcare professional was good or very good at listening to them. The national average was 85%. The national patient survey showed that 99% of patients said they had confidence and trust in the healthcare professional they saw or spoke to. The national average was 93%. CQC have received 1 complaint in the last 12 months. CQC did not speak to patients on the day of the on-site inspection.

Leaders explained how people's immediate and ongoing needs were fully assessed, and patients’ treatment was regularly reviewed and updated. This included their clinical needs and their mental and physical wellbeing. In addition, how patients presenting with symptoms which could indicate serious illness were followed up in a timely and appropriate way. Staff explained they had a call and recall policy for patients who required chronic disease management, cervical screening tests, childhood immunisations, or those who took certain medicines requiring regular blood tests. Leaders and staff explained that all abnormal blood tests were followed up and they had a protocol for workflow, emails, post and test results in place. Leaders explained patients were told when they needed to seek further help and what to do if their condition deteriorated. Leaders and staff told us codes and alerts were added to patient records to ensure people’s communication, disabilities and any impairment needs were highlighted for staff to tailor patient care. Staff told us they checked patient’s health, care, wellbeing, and communication needs during health reviews. The practice held a register identifying people with caring responsibilities. The practice worked closely with their care coordinator to assist people access additional support within the local community.

The practice had systems to identify and prioritise care and treatment for its most vulnerable patients. For example, we saw that all patients with a learning disability were offered an annual health check. 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. We also reviewed a sample of patients records who may have an undiagnosed long-term condition. These searches were visible to the practice. We viewed the records for 5 patients identified as having a potential missed diagnosis of diabetes out of a total of 56 identified in our clinical search and found no serious concerns. We carried out 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 follow up correctly. We identified 223 patients with asthma and 3 who had received the 2 or more courses. We reviewed these 3 patients records and found the patients had an asthma review documented in their records in the past 12 months. However, two patients had not been followed up to check response to treatment within a week of an acute exacerbation. The search for patients with the possible diagnosis of kidney disease following a blood test result, identified all patients had been diagnosed. We sampled 5 patient records to check this and found no concerns. The clinical searches identified a total of 98 patients with hypothyroidism. During our review of records, we found that patients with hypothyroidism were monitored appropriately and had thyroid function test monitoring in the last 18 months. We reviewed a sample of 5 patients’ annual care plans for patients who had a learning disability or severe mental health and found no concerns.

During this assessment we were only able to speak with one patient, they were happy with the care and treatment they received from the practice.

People’s care and treatment was planned and delivered in line with evidence-based guidelines, standards and current legislation. There were appropriate referral pathways to make sure that patients’ needs were addressed. There were clear and effective arrangements for following up on people who have been referred to other services. Staff provided care and treatment in line with national guidance. The practice had systems and processes to keep clinicians up to date with current evidence-based practice. We checked patient records and reviewed a range of consultation notes, medication reviews and saw that in the main, appropriate care and treatment was given.

The staff discussed patient care at monthly clinical, safeguarding and integrated care team meetings. A review of a sample of patients’ clinical records demonstrated they had received evidence-based care. The staff had completed some clinical audits to ensure they were meeting clinical guidelines. The governance lead monitored the practices clinical performance monthly.

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

Staff worked together and with other organisations to deliver effective care and treatment. The practice held monthly multi-disciplinary team (MDT) meetings. Leaders held weekly clinical team meetings where they discussed patients and any concerns. 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 and complexity of people's needs. Shared care agreements were made with secondary care providers regarding the prescribing and monitoring of patient medication. Staff told us they provide support for patients who struggle with booking appointments for different services and a social prescriber also provided support to patients.

We received some feedback from external partners. Primary care commissioners told us they were unaware of any current performance concerns related to this practice. We had no feedback from any other external partners.

There was evidence of comprehensive assessment to establish individual needs and preferences. We saw no evidence of discrimination when staff made care and treatment decisions. We reviewed a range of consultation notes, medication reviews and saw appropriate care and treatment was given.

Patients had access to appropriate health assessments and checks. During this assessment we were only able to speak with one patient, they told us they had been provided with information on healthy lifestyles and also managing their long-term condition.

The practice identified patients who may need extra support and directed them to relevant services. Staff were consistent and proactive in helping patients to live healthier lives. Staff kept a register of patients with a learning disability and there were alerts on medical records to help staff identify patients when they contacted the practice. The practice had signed up to Doctors of the World Safe Surgery initiative. A Safe Surgery can be any GP practice which commits to taking steps to tackle the barriers faced by many vulnerable migrants in accessing healthcare.

Staff encouraged and supported patients to be involved in monitoring and managing their own health. We reviewed a range of consultation notes, medication reviews and saw appropriate care and treatment was given. Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.

During this assessment we were only able to speak with one patient, they feedback they had no concerns about the care and treatment they had received from the practice.

Leaders followed national guidance to routinely monitor people’s care and treatment to continuously improve it.

The practice monitored the outcomes of care and treatment for their patient population. The practice had a programme of targeted quality improvement and used information about care and treatment to make improvements. The provider had created a cloud based automated call and recall system to improve management of patients with chronic diseases, for example, hypertension, diabetes and atrial fibrillation. The system used automated and scheduled searches which generated a reminder message to patients to come in for medicine reviews based on risk stratification. The platform was successfully piloted between October 2022 and September 2023 and outcomes showed a significant improvement in chronic disease management. The practice had process in place to invite patients in for high-risk medicines monitoring.

The NHS Business Services Authority (NHSBSA) medicines data from 1 October 2022 to 30 September 2023 for the average daily quantity of hypnotics prescribed per specific therapeutic group were in line with the national average for prescribing. The number of prescription items for antibacterials co-amoxiclav, cephalosporins and quinolones as a percentage of the total number of prescription items for selected antibacterial drugs was better than the national average for prescribing. From 1 October 2022 to 30 September 2023, the medicines data demonstrated that Nitrofurantoin, Pivmecillinam and Trimethoprim tablets prescribed for uncomplicated urinary tract infection and the total items prescribed of Pregabalin or Gabapentin per 1,000 patients were in line with the national average for prescribing. The number of unique patients prescribed multiple psychotropics per 1,000 patients was in line with the national average.

During this assessment we were only able to speak with one patient we did not get their view about their rights around consent.

Staff told us consent to care and treatment was always obtained, this could be verbal as well as written and we saw that consent was documented.

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were made in line with relevant legislation. We reviewed DNACPR records and saw appropriate consent was obtained.