Bellbrooke 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

Overall, we found that the practice provided effective care and treatment. However, we found some issues with ongoing monitoring for patients at risk of diabetes. Staff had access to training and learning opportunities to keep them up to date with the latest guidance. The practice engaged with other services and supported patients to manage their health and wellbeing. A review of clinical records showed that the management of patients with long-term conditions was effectively managed. However, childhood vaccinations and cervical screening uptake rates were below national targets despite efforts from the practice to promote and encourage uptake.

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.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

We spoke with members of the management team who explained how patients requiring monitoring were supported and managed. This included inviting for annual health reviews and monitoring checks.

Patient’s accessibility and communication needs were recorded, and they were supported accordingly. There was a care navigation process in place and staff received training for this. The practice had a palliative care register with 68 patients and these patients were reviewed in regular Gold Standards meetings and supported to make informed decisions about their future. There was a dedicated advanced nurse practitioner to support frail and housebound patients. A review of clinical records showed that the management of patients with long-term conditions including asthma, chronic kidney disease, diabetic retinopathy and hypothyroidism was effectively managed. Staff could refer people with social needs, such as those experiencing social isolation, to a patient ambassador. As part of our clinical searches, we reviewed potential missed diagnosis of diabetes. Of 45 patients identified in this category, 5 were reviewed and 2 had been appropriately coded as pre-diabetic, however further blood tests were required for these patients as it had been more than 3 months since their last tests.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Clinical staff told us they followed best practice guidance when carrying out their work. They also told us they had access to training and learning opportunities and were supported with their professional development.

The practice had systems and processes in place to keep clinical staff up to date with current evidence-based practice. We saw several examples of this, including staff undertaking apprenticeships and attending nurse forums. However, as part of our clinical searches we reviewed 5 patients prescribed Methotrexate and noted that 3 patients did not have the day of the week included on the prescription in line with National Institute for Clinical Excellence (NICE) guidance.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Staff and leaders told us about services they worked closely with. This included, for example, members of the primary care network, an alcohol detox service, and third sector organisations.

As part of the assessment process, we asked the NHS West Yorkshire Integrated Care Board to share their experience of the service. There was no feedback to indicate concern in this area.

We saw there had been engagement with external bodies, for example the Local Medical Committee, in order to help drive improvement within the practice. Multidisciplinary team meetings were held to discuss clinical cases and patients on the palliative care register. The practice had created space at the premises for members of the primary care network (PCN) such as patient ambassadors, first contact practitioners, and the mental health team, which allowed more joined-up working with these services.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Staff told us about the ways in which they supported patients to manage their health and wellbeing, and to live healthier lives. This included referral to the in-house patient ambassadors and encouraging patients to attend health checks and reviews. Staff were aware that uptake rates for childhood immunisations and cervical screening were lower than local and national averages and were taking steps to improve this.

There were in-house patient ambassadors who signposted patients to relevant services to support and improve their health and wellbeing, for example to mental health support services. Information to support patients was also available on the practice website.

The GP Patient Survey for 2024 showed that practice performance in areas such as patients having enough support from local services or organisations to manage long-term conditions, was in line with the national average.

Staff we spoke with could clearly outline the systems in place to recall and review patients and understood their role in this process. Staff told us how they took a proactive approach to encourage patients to attend for cervical screening and childhood immunisations, for example through promotion in community groups.

Our review of patient clinical records showed the practice worked with patients to monitor and improve outcomes. This included the management of patients with long-term conditions. Clinical indicators were regularly reviewed to try and ensure that targets were met in each area. The practice worked with different community groups and organisations to promote and encourage uptake of cervical screening and childhood immunisations. They had also taken part in a project for women who had suffered trauma, in order to improve their communication and environment for these patients. Appropriate registers were held to ensure effective monitoring of specific groups such as those on palliative care.

Our review of the remote clinical searches of patient records showed that regular reviews were undertaken for those patients with long-term conditions. The practice’s cervical screening uptake rate at June 2023 was at 54%, which was below the 80% national target. The practice’s childhood immunisation uptake rates at March 2023 were below 65%, which was below the 90% national minimum target.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Staff told us how they dealt with consent and how they helped patients make decisions about their care, including the use of relevant guidelines and recording consent. Staff also told us how they worked with patients, and their carers, to support them to understand their options regarding Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions.

There was a consent policy in place which covered areas such as capacity and consent. Carers and advocates were involved in consultation processes where required, and resources were used to support patient’s understanding of their treatment. Processes were in place to support patients to make informed decisions about their future, and to review patients at the end of their lives. We saw that DNACPR and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms were completed in line with guidance and with the input of patients, and when necessary, their carers.