Russell Street Group practice

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 assessed 4 quality statements from this key question. We found quality improvement processes were in place and outcomes from audits were used to review the effectiveness and appropriateness of care or treatment provided, and partners spoke positively about the coordination of care between services. However, we also found national guidance regarding the care of patients with long term conditions was not always followed, there was limited monitoring of the outcomes of care and treatment, and a number of staff had not had appraisals or supervision in the last 12 months.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s feedback told us they felt involved in the assessment of their needs. The 2023 national GP Patient Survey data regarding assessing needs and patient involvement were in line with local and national averages. For example, the percentage of respondents who responded positively to involvement in decisions about their care and treatment was 84% and this was comparable to the local average (92%) and national average (90%).

Staff told us they prioritised patients who were clinically vulnerable to ensure their needs were assessed and any immediate care and treatment was delivered. However, we were not assured patients presenting with symptoms which could indicate serious illness were followed up in a timely and appropriate way. For example, we were alerted to a significant event which had not been reported or learned from where a patient had been left for a significant period in the waiting area and later resulted in hospital attendance. Once we highlighted this to the practice, we noted they formally reported and investigated the event. However, we were not assured staff had been given appropriate training in response to this event to ensure they knew how to assess urgent needs of patients in the future. Leaders and staff told us they used codes, alerts and flags which they added to patient records to ensure patients’ communication, disabilities and any impairment needs were highlighted for staff to tailor patient care. Staff told us the needs of carers of people using services were assessed and support offered, however, we noted the carers register had only identified 34 carers across the patient population of approximately 8,900. Staff told us they checked and assessed patient’s health, care, wellbeing, and communication needs during health reviews.

The practice had some systems in place to identify and prioritise care and treatment for its most vulnerable patients. For example, the practice had completed 80% of their annual health checks for patients with learning disabilities. However, the practice did not have an effective system in place to monitor and maintain effective oversight of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. For example, our remote searches identified only 4 patients on their DNACPR register despite the practice providing support to 2 local care homes. We were therefore not assured that patients had access to personalised support about DNACPR decisions. We also found the practice did not have a named palliative care lead and had not attended any palliative care meetings for 12 months. The provider told us this was due to having only 2 patients on the palliative care register, however, we were not assured the practice had properly identified the prevalence of palliative patients and this meant there was a risk that some patients did not have access to the necessary support and care to meet their needs.

We noted 93% of patients who responded to the GP patient survey in 2023 stated they had confidence and trust in the healthcare professional they saw or spoke to during their last GP appointment. Patient feedback also told us they felt involved in their care and treatment and staff explained treatment and risks in a way they understood. This was in line with the 2023 GP patient survey results which showed 84% patients stated they were involved in decisions about their care and treatment, which was comparable to the local and national averages.

Staff told us they were provided opportunities to keep up to date with current guidelines and changes to evidence-based care and treatment and we saw some evidence this had been discussed in clinical meetings. However, our remote searches identified a lack of oversight of some long-term condition management to ensure evidence-based care and treatment was given to patients within appropriate timeframes.

The remote searches undertaken of the practice’s clinical patient records system identified monitoring of patients with some long-term conditions were not always followed in line with current legislation, standards and evidence-based guidance including from the National Institute for Health and Care Excellence (NICE), referred to as NICE guidance. These searches demonstrated the provider did not ensure consistent delivery of evidence-based care as systems and processes were not established and operated effectively. For example, out of the 488 patients on the asthma register, 35 patients (7%) had been prescribed 2 or more courses of rescue steroids in the last 12 months. We reviewed 5 of these patients in detail and identified none had been followed up to check their response to treatment following exacerbation of their asthma within a week, as required by NICE guidance. Searches also identified 18 patients as having heart failure and 6 of these patients (33%) had been prescribed aldosterone antagonist (a diuretic medicine) without the required monitoring. We reviewed 5 of these patients in detail and identified none had been monitored in line with NICE guidance (monthly monitoring for first 3 months, then every 3 months for 1 year, and then every 6 months).

Patient feedback through CQC ‘Give Feedback on Care’ and an external online review website showed 3 patients had raised concerns about referrals not being done in a timely manner and we identified concerns with a lack of oversight over administrative tasks, including tasks to complete referrals for patients which dated back to October 2023. However, we received patient feedback from 4 patients during the assessment and they did not raise concerns regarding referrals, the coordination of care within the practice or between the service and external providers.

Most staff told us they worked as a cohesive team to ensure patients received high quality healthcare. However, some staff told us that due to lots of new staff members joining and due to a lack of team meetings, the practice team sometimes felt disconnected. Despite this, all staff told us they felt positive about the new practice manager and felt hopeful team working would improve. Staff informed us there were processes for managing correspondence and referrals to external services. However, we found 5,113 tasks within the clinical system which dated back to October 2023 and it was unclear if these tasks had been actioned.

Both local care homes provided feedback that the GPs were supportive of all care home staff and patients. They told us all GP practice staff were dedicated to ensure patient care was coordinated effectively to allow patients to access the care and support they needed.

Staff had access to the information they needed to appropriately assess, plan and deliver people’s care, treatment and support. However, the process in place to action and manage correspondence and referrals to external services was not effective as we identified 5,113 tasks which required action and dated back to October 2023. In addition, we found a significant event had been reported in November 2023 where a referral for a patient had been missed and GPs were reminded to complete non urgent referrals and letters within 7 days of the consultation.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

Patient feedback did not include reference to the monitoring and improving outcomes of care. However, we received feedback from local care homes who told us residents were offered annual health checks and proactive care was provided.

Leaders told us they undertook quality improvement audits and used the information about care and treatment to make improvements. Leaders told us they regularly discussed outcomes for patients at clinical meetings, including reviewing the practice Quality Outcome Framework (QOF) achievements and determining what action was required to make further improvements. The QOF incentive scheme rewards practices for the provision of 'quality care' and helps to fund further improvements in the delivery of clinical care. For example, following a clinical meeting in January 2024, a weekend clinic was organised to offer reviews for patients with learning disabilities and this helped to contribute to 80% of the learning disability annual health checks being completed.

The practice had a programme of quality improvement activity which included carrying out audits to review the effectiveness and appropriateness of care or treatment provided. The practice used information collected for the QOF and performance against national screening programmes to monitor outcomes for patients. Whilst staff told us they monitored outcomes, we saw there were ineffective systems and processes to recall and monitor patients which contributed to a low QOF achievement.

In the most recent verified QOF submission (2022/23), the practice achieved 62.9% QOF points, which was below the Sub ICB average (88.6%) and national average (90.4%). The practice was an outlier for various QOF (or other national) clinical targets including asthma, chronic obstructive pulmonary disease, diabetes and hypertension. The practice did not meet the minimum 80% target of eligible patient uptake of cervical screening with the June 2023 verified data by UK Health and Security Agency (UKHSA) uptake being 63%. From a review of the practice appointment system, cervical screening appointments were available to book in advance. The practice had a dedicated staff member in place to make contact with eligible patients and offer them an appointment and a practice nurse had been recently appointed as lead for cervical screening to help to focus on and improve uptake. We noted practice data from March 2023 showed screening for 25-49 year olds was 66% and for 50-64 year olds was 82%. The provider acknowledged the need for further improvements to cervical screening uptake and continued to work with other stakeholders to strive towards meeting the 80% target. Published and verified data by UKHSA from March 2023 showed that the practice did not meet 4 of the 5 child immunisation targets. The practice was aware of the challenges they faced with reaching their target and had a dedicated staff member to run the list of eligible patients monthly and would make further attempts to invite them in.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.