Holyhead Primary Healthcare 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 carried out an announced assessment of all 6 quality statements under the effective key question. We found people and communities had the best possible outcomes because their needs were assessed. We found staff involved people in decisions about their care and treatment and provided them with advice and support. Services worked in harmony, with people at the centre of their care. The practice functioned as a hub for their community for the provision of health prevention and promotion education. This included outreach work into religious institutions and libraries to provide better access to basic health checks and health information for everyone in their local population. The practice had a clear understanding of the needs of their patients and provided services accordingly such as in-house translators, TB screening programs, smoking cessation clinics and diabetes education programs.

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 that staff had enough information about them as an individual to provide tailored treatment. In the 2024 National GP patient survey, of the patients who answered the question, 94% felt that their healthcare professional had all the information they needed about them. This was above the national average of 92%. When asked if the healthcare professional was good at considering their mental wellbeing, 80% said yes, which was above the national average of 73%.

We found that staff and leaders understood the needs of their patient population and used this information to design services that met those needs. For example, the local population had high percentages of Romanian and Asian people; the practice provided in-house interpreters in the relevant languages who were on-site every day between 10am and 4pm to facilitate swift access to translation for this patient group. Staff told us that patients with protected characteristics who required reasonable adjustments were supported by digital flagging on the clinical system which described the adjustments required. For example, staff told us that patients who were neurodiverse or with a learning disability could request appointments at quieter times of the day and avoid using the waiting room as they were given priority access straight to the GP’s clinic room. Staff described how they followed up patients who did not attend, especially those who did not attend for cervical screening appointments and how they provided opportunistic education for these patients explaining why such screening was important.

We saw no evidence of discrimination when staff made care and treatment decisions. Patients were told when they needed to seek further help and what to do if their condition deteriorated. The searches and record reviews we carried out looking at patients with long term conditions found that their reviews were up to date. We found the practice to be effective and consistent in identifying patients with undiagnosed conditions. The practice held registers of various patient groups to facilitate care that met their specific needs. There were 92 registered carers (1% of the practice list) and the practice offered them carer health-checks and priority flu vaccinations. The practice had a palliative care lead and kept a register of patients who were palliative. The register was kept under regular review. Patients on the register had all been assessed and were discussed in meetings and/or reviewed accordingly. Patients on the Learning Disability register were offered annual health checks, of which the practice had completed 92% and been acknowledged by the ICB for its good practice.

Patient feedback we viewed during this assessment was positive about the service that patients had received. In the 2024 National GP patient survey 85% of people who responded to the survey felt their needs were met at their last appointment. This was below the local average of 87% and national average of 90%.

Leaders told us patients received care, treatment and support that was evidence-based and in line with good practice standards. Patients are told about current good practice that is relevant to their care and this was reflected in their care plan. Patients had access to appropriate health checks and assessments and were directed to relevant services when they needed extra support, such as those at risk of developing a long-term condition or health promotion services like smoking cessation. Patients were encouraged to be involved in monitoring and managing their own health.

The practice had systems in place to share new guidelines and updates in clinical care. The searches we carried out as part of this assessment found 10 patients out of 210 diagnosed with asthma had required 2 or more courses of rescue steroids (these are medicines to treat an exacerbation of asthma) in the last 12 months. We reviewed 5 of these records and found that none of these 5 patients had been reviewed within 1 week of having the rescue steroid in-line with guidelines. We discussed these findings with the practice partners and they told us they had taken immediate action to add an electronic reminder onto the clinical system to ensure patients were reviewed appropriately following prescription of rescue steroids. We found the practice monitored all patients with Diabetes, Chronic Kidney Disease (CKD) and hypothyroidism (an underactive thyroid gland) in-line with current guidance. Leaders had prioritised the management of long-term condition reviews when they took over the practice. Staff had worked to maintain patient safety by carrying out monthly searches of the clinical systems to identify relevant patients. There was program of audit and quality improvement, this ensured that care was being delivered in line with best practice. For example, a recent audit of the prescription of thyroid medication identified 6 patients who no longer needed the medication. Another example was the creation of a register of all patients taking anticoagulant (blood thinning) medications. This allowed monitoring of their CHAD score (congestive heart failure, hypertension (high blood pressure), aged over 75 years, diabetes and previous stroke) and creatinine clearance rate (a test for kidney function) to be done regularly. The practice held a monthly clinical governance meeting where issues relating to clinical practice were discussed within the whole team. Staff maintained effective and regular communication with other services who were involved in the care of their patients.

Patients we spoke with and feedback we reviewed demonstrated patients were positive about their experiences of being referred to other services. Our assessment did not provide any cause for concern in this regard.

Staff and leaders were confident in sharing how they worked together and with other services to support patients. They said they had access to the information they needed to appropriately assess, plan and deliver patient’s care, treatment and support. Advice and support were available to all staff when it was needed. Staff felt that communication was good, they valued the regular whole staff clinical governance meeting as a forum to share information, concerns or ideas and felt the open-door policy of the leadership to be effective. Staff shared examples where they had worked together with different teams or external organisations to safeguard patients, improve patient experience and/or optimise care and treatment for patients. Staff tried to ensure continuity in care for patients where possible.

Feedback we received from partners who worked with the practice reported that communication was timely, effective, and patients were referred smoothly.

Evidence demonstrated there were effective systems to share information between teams and services to ensure continuity of care, such as when clinical tasks were delegated or when people were referred between services. Multidisciplinary teams met regularly to discuss and support vulnerable patients. These meetings were documented to ensure actions were completed as required. There were safety-netting processes in place to ensure the safe and effective delivery of care. There were processes in place to support the effective assessment and treatment of patients with more complex needs.

Patients felt supported to manage their health and wellbeing. Data from the 2024 National GP patient survey showed that 56% of people who responded felt they had enough support from local services or organisations, this was below the national average of 68%. Patients we spoke with reported that they were invited for screening appointments and vaccinations. Unverified feedback obtained by the practice from 15 patients who attended their diabetes management program showed 87% were satisfied, 93% felt it would help them manage their condition and 87% would recommend it to a family member or friend.

Leaders were enthusiastic in telling us about the various ways in which the practice supported patients to make healthy choices and lead healthier lives. The practice had 2 social prescribers who along with various accredited external organisations ran a variety of sessions for patients including diabetes and weight management, carer and dementia support, menopause awareness, and housing support. The social prescribers also did outreach sessions in community locations such as the library and religious institutions providing basic health checks such as blood pressure readings. Staff told us about their successful smoking cessation program where they had been the top performing practice in the West Midlands for 4 week quits in the previous 2 quarters of 2024. Staff and leaders reported they were proud of their achievements in performing 295 NHS health checks in the 2nd quarter of 2024 and screening 124 patients for TB in 5 months. This data was provided by the practice and is unverified.

We found there were effective processes in place to support patients to make positive decisions about their health and lifestyle. Staff were able to refer patients to a range of support and education groups held within the practice. Social prescribers also provided one to one appointments if required. We saw a variety of information leaflets and posters informing patients about local services and support groups in the waiting room at the practice. Some of these were in other languages than English. Further information was displayed on the television screen in the waiting room. We did not however see any information signposting young people to sexual health services. The practice leaflets and leaflets about national screening programs were available in different languages. We saw a robust system to support the provision of national breast and bowel cancer screening programs. A dedicated member of the reception team monitored all patients called for the screening programs; they contacted patients with an interpreter to ensure they understood why attendance for screening was important. The unverified data the surgery gave us showed this has increased uptake from 23% to 60%. The practice website had a comprehensive range of health promotion, preventative and self-treatment information.

We could not collect specific evidence from patient feedback to score this evidence category. The practice shared with us examples of how they routinely monitored people’s care and treatment to continuously improve it, including in response to patient’s feedback. The evidence we reviewed did not show any concerns about people’s experience regarding monitoring and improving outcomes.

Staff discussed performance, patient experience and outcomes during clinical governance meetings. This helped staff to maintain and improve continuity of care, safe systems and patient satisfaction. Staff carried out regular searches and additional clinical audits to measure outcomes and provide leaders with oversight of performance. Findings from audits were shared with staff to help identify further areas for improvement. Leaders monitored and acted on information from various sources including patient feedback, clinical audits, complaints and incidents.

There were effective approaches to monitor people’s care and treatment and their outcomes. The practice used a variety of data to analyse performance and outcomes for patients. This analysis then informed services developments, for example the 2023 National GP patient survey results showed 11% of patients could access local services. The practice expanded its offer of local support services in response and in 2024 this had increased to 58%. There were robust audit processes in place to ensure that a result was obtained for every cervical screening sample taken and action was taken to recall the necessary patients. Nursing staff were given feedback on the percentage of inadequate samples to allow them to monitor their own competence and performance.

The practice demonstrated that all patients who had long-term conditions or were on medicines that required regular monitoring received their monitoring and reviews in line with evidence-based guidance. Leaders described the work that had been undertaken to improve uptake of national bowel and breast cancer screening programmes, including education in multiple languages, robust recall systems and dedicated reception staff to who took ownership of this work. We found leaders were aware that historically, the practice was not meeting national targets for some childhood immunisations. However, this data related to the period between 01/04/2022 and 31/03/2023 which was before the current provider had taken over the practice on 01/04/2023. Since then, leaders had implemented sound measures to improve the uptake of childhood immunisations. For example, staff we spoke with advised us that all children who were not brought to any type of appointments (not limited to appointments for vaccination) in primary or secondary care were followed up and repeated failed attendances triggered safeguarding processes. For cervical cancer screening, verified data was only available for the time period 31/3/23/ to 30/6/23 since the new registration of this practice which showed a downward trend in the first 3 months of the provider’s tenure from 65.36% to 61.97%. We saw that staff and leaders were working hard to encourage people to attend for screening, for example, staff we spoke with advised of measures in place to support uptake of the cervical screening programme, including flexible appointments, multiple reminder phone-calls and texts, educational telephone calls from a doctor for patients who were uncertain whether to have screening and follow ups to failed appointments

Patients we spoke with and the evidence we reviewed did not raise any concerns around consent. People understood their rights around consent to the care and treatment they were offered.

Clinicians understood the requirements of legislation and guidance when considering consent. Clinicians supported patients to make decisions ensuring their views and wishes were considered during care planning. Assessments of mental capacity were carried out when needed and were decision specific. Staff told us they were able to adapt or translate information about care and treatment so that patients could understand, to support them making informed decisions. There were systems and practices to ensure that people understood the care and treatment being offered or recommended. All staff we spoke to had completed relevant training and were able to discuss how to gain informed consent for treatment. Most staff (who were not a GP) told us if they were not confident to assess whether someone lacked capacity, they would seek advice from a GP.

A random review of 5 staff training records showed all staff had up-to-date training on informed consent, the 2005 Mental Capacity Act and the Deprivation of Liberty Safeguards (DoLS). We saw that consent was documented and processes were in place for chaperones to be present if requested. We reviewed a random sample of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions and found that they were made in line with relevant legislation and were reviewed regularly. Staff made decisions within the requirements of the Mental Capacity Act 2005 including the duty to consult others such as carers, families and/or advocates, where appropriate.