Dudley Wood 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

At the last inspection we found that the management of patients with long term conditions needed improving, patients’ needs were not always assessed and care and treatment was not always delivered in line with current legislation, standards and evidence-based guidelines and t was limited clinical oversight and a lack of supervision. At this inspection, we found that significant improvements had been made and there were systems and processes for assessing needs, delivering evidence based care and treatment, monitoring and improving outcomes and supporting people to live healthier lives. We saw evidence of how staff, teams and services worked together to provide effective care to patients.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice used codes and alerts on patients records to highlight any communication needs and any impairments. The practice had systems and processes in place to identify people’s needs and preferences during the registration process. We found that systems and processes to ensure the safe, care and treatment of patients had been strengthened and there were processes to keep clinicians up to date with current evidence-based practice. We found pathology, cytology and other test results via workflow had been reviewed in a timely manner, and there were effective systems and processes in place to ensure that staff had the sufficient information to inform their treatment decisions. We found the practice held registers which were reviewed to prioritise care for their most clinically vulnerable patients. For example, we reviewed a patient with a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) record to consider whether the DNACPR had been prepared and found this had been reviewed and agreed appropriately. Effective care for the practice population had been strengthened and those patients identified were recalled and received an assessment of their needs.

Information reviewed demonstrated that people’s needs were assessed. For example, 91% of patients felt their needs were met during their last GP appointment and 91% of patients felt that the healthcare professional recognised or understood any mental health needs during their last general practice appointment.

Leaders and staff told us the practice used codes and alerts on patients records to highlight any communication needs and any impairments. There were appropriate referral pathways to make sure that patients’ needs were addressed. We spoke with staff who were able to describe the process for coding of correspondence and care and treatment records for people. Staff we spoke to were aware of the workflow and clinical staff were able to demonstrate how the practice provided further education and support to patients. We found that staff had the appropriate skills and training to carry out reviews where appropriate.

Leaders told us they had reviewed their systems in line with good practice standards and were reviewing quality improvement through audits and checking care is consistently provided in line with guidance. We found that the provider had carried out clinical audits in the last 6 months as quality improvement and used information about care and treatment to make improvements. For example, we found that audits had been carried out in relation to measles, mumps and rubella (MMR), Direct oral anticoagulants (DOACs) and Lipid optimisation for secondary prevention. At the last inspection we found that long term condition monitoring and annual reviews for patients with mental health and a learning disability required strengthening. Staff told us they had reviewed this further and processes had been strengthened to recall and review people with long-term conditions according to monitoring requirements. At the last inspection the practice had been without a permanent nurse to carry out asthma reviews, however they had secured a long term locum nurse to support them for the next 12 months. Staff told us they received appropriate training and guidance in relation to medicines administered through Patient Group Directions or Patient Specific Directions.

We found people with long-term conditions were offered a structured annual review to check their health and medicines needs were being met. The remote clinical searches that we undertook of the practice’s clinical records system showed the monitoring of people with some long-term conditions were followed in line with National Institute for Health and Care Excellence (NICE) recommendations. For example, we identified 99 people with hypothyroidism, a condition which results in low activity of the thyroid gland. Of those, 1 person had not received the appropriate blood monitoring, however the practice had taken appropriate action. During our clinical records review, we identified 12 people with high-risk diabetes, and found that 10 people had been reviewed and 2 appropriate action was in place. We identified 12 people with later stage chronic kidney disease and found that 2 patients were overdue monitoring, however the provider had arranged reviews for both patients. We found people with acute exacerbations of asthma were followed-up in line with national guidelines to provide safe and effective care and treatment, however we found a lack there was a lack of contemporaneous notes for some medicine reviews. Staff had the appropriate authorisations to administer medicines through Patient Group Directions or Patient Specific Directions.

The GP patient survey demonstrated that 88% of patients felt they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment and 91% had confidence and trust in the healthcare professional they saw or spoke to during their last general practice appointment which was in line with local averages.

There were systems and processes in place to enable information to be shared between the provider and services to ensure continuity of care. Regular meetings were held with multi-disciplinary teams to ensure care is coordinated effectively. The primary care network (PCN) helped to support the practice by providing links to pharmacists, dieticians, mental health practitioners and social prescribers. People were able to receive coordinated care between the practice and the primary care network. Systems were in place to share information about patients electronically with other services. Clinical meetings were held weekly and practice meetings had been re-established to ensure all staff were kept up to date with guidance and best practice.

Staff told us how they worked together with other organisations to deliver effective care and treatment. There were regular integrated care meetings with community health care staff as part of the primary care network to discuss the care and support needs of all patients. The provider told us that meetings had been reestablished with the health visitor as part of strengthening their safeguarding processes and clinical meetings were held weekly. Staff told us that they had access to the information they need to appropriately assess, plan and deliver people’s care, treatment and support; and they had enough information to plan and refer people and receive subsequent results and information following referral.

The GP lead told us that they had strengthened systems and processes with other services. For example, meetings had been res-established with the health visitor and there was regular attendance to multi-disciplinary meetings to ensure care for patients is coordinated and planned effectively.

At the last inspection we found there were difficulties in recruiting clinicians, which had led to some delays in carrying out annual reviews and monitoring for patients. However, we were told that the practice had secured a long term locum nurse to support asthma reviews. A long term locum GP had also been recruited and there were lead roles in place and regular practice meetings to ensure staff were consistent in helping patients live healthier lives.

Processes had been strengthened to support people to live healthier lives. There were flags on patients who were vulnerable and required ongoing monitoring and recalls in place to review patients and educate them to manage their health needs. There was regular engagement with community services and referral pathways in place. The practice website detailed information and links for health promotion, health conditions and common health questions.

The practice had strengthened their systems to ensure that those patients requiring medicine reviews and ongoing monitoring were actively being reviewed and recalled. At the previous inspection we found a backlog in reviews carried out for those patients with a learning disability and mental health. At this inspection we found that action had been taken and was able to evidence that 91% of annual learning disability and 100% of mental health reviews had been carried out. There were systems in place to identify and manage patients who required monitoring. Our clinical searches that were carried out demonstrated that improvements had been made. In addition, we were able to evidence that clinical audits were being carried out to monitor and improve outcomes for patients.

Staff told us that they had reviewed their systems further to ensure that that patients were being routinely monitored. At the last inspection we identified that some annual reviews had not been routinely carried out for those patients with a long term condition. To address this, the practice had secured a long term locum nurse and health care assistant to support the delivery of long term condition monitoring.

We found that processes had been strengthened and there were systems to recall and monitor patients with long term conditions and those who were prescribed high risk medicines and required regular monitoring. The practice had implemented a number of clinical audits to ensure the quality and safety of people’s care and treatment is effectively monitored, and that the practice continuously improve their outcomes.

The GP patient survey demonstrated that 61% of patients said they have had enough support from local services or organisations in the last 12 months to help manage their long-term condition(s) which was in line with local averages.

We saw evidence that consent was obtained for patients so that they understand their rights around consent to the care and treatment they are offered. The GP survey demonstrated that 88% of patients were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment.

We spoke to staff who was able to demonstrate the requirements of legislation when considering consent and decision making and had access to policies to support them. All staff had completed training on mental capacity and understood legislation when considering consent and decision making.

We found that the practice had strengthened their processes for consent to care and treatment in line with legislation and guidance. At the last inspection, we found that Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) required strengthening to ensure DNACPR’s accurately reflected the most recent decision. We found that action had been taken and there was a DNACPR policy in place. All staff had completed training for mental capacity, learning disability and autism. We found that Clinicians understood the requirements of legislation and guidance when considering consent and decision making and saw that consent was documented.