Graham Road 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

We assessed all quality statements in the effective key question. Our rating for this key question is now good. Staff included people in the assessment of their needs, and support was provided where needed to maximise their involvement. The national GP Patient Survey results indicated patients felt involved in their care and treatment and felt their needs were met. People’s care was regularly reviewed, and staff worked with other services to achieve this.

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.

People felt involved in the assessment of their needs and they felt confident staff understood their individual needs. However, feedback from people we received indicated access was challenging and people could not get an appointment to get their needs assessed.

Staff were aware of the needs of the local community. Digital flags on care records highlighted to staff any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff demonstrated an understanding of the additional support some patients may need when attending their appointment such as requiring a translator.

Care and treatment was regularly reviewed and updated. There were appropriate referral pathways to make sure that patients’ needs were addressed. Patients presenting with symptoms which could indicate serious illness were followed up in a timely and appropriate way. Patients with long-term conditions were offered an effective annual review to check their health and medicines needs were being met. Our clinical searches identified 614 patients on the asthma register and 41 of those patients had been prescribed 2 or more rescue steroids (treatment for severed asthma episodes) in the last 12 months. We reviewed 5 of these patient records and all 5 had been reviewed appropriately in line with national guidance including an assessment at the time of prescribing and a follow up to check the response to treatment. We reviewed the appointment diary and saw appointments were available to book the same day for urgent appointments and in the following few days for non-urgent appointments.

We received no specific feedback in this area.

Clinicians kept up to date with current evidence-based practice. Staff who were responsible for reviews of patients with long-term conditions had received specific training. Staff attended a monthly training session delivered to all locations by the provider and found this useful learning to support the care and treatment they delivered.

The practice had systems and processes to keep clinicians up to date with current evidence-based practice. Care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools. Our clinical searches identified 7 patients who had a potential missed diagnosis of diabetes. We reviewed 5 patient records and found all 5 had been monitored appropriately.

We received no specific feedback in this area

Staff appreciated their colleagues and liked the team working environment. They were aware of the value of working across services and sharing knowledge and experiences to get the best outcomes for people. Leaders welcomed partnership working and had met regularly with the local Integrated Care Board (ICB) to make improvements following their last CQC inspection.

Feedback from partners indicated their experience of staff from the practice varied. Although regular visits by these named members of staff were sometimes useful, partners felt on occasion, communication was obstructive, and they were dismissed or challenged when requesting information or medicines for patients.

Regular meetings were held between the practice and other health and social care services to ensure continuity of care. Care was delivered and reviewed in a coordinated way when different teams, services or organisations were involved. Patients with poor mental health were referred to appropriate services in the community. Patients received consistent, coordinated, person-centred care when they moved between services. At the time of the inspection, the practice did not have a process to seek feedback from providers. However, when we informed the provider of the mixed feedback we had received, and they said they would consider a formal process.

We received no specific feedback in this area.

Staff encouraged and supported patients to be involved in monitoring and managing their own health. Staff discussed changes to care or treatment with patients and their carers as necessary. Staff had a holistic, joined up approach to supporting people and would discuss patients care within practice, multidisciplinary meetings and daily huddles.

The practice identified patients who may need extra support and directed them to relevant services. This included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers. The practice website contained information and links to other sources of information to support patients to make healthier choices.

People had no specific feedback in this area.

Patients were reviewed or monitored at appropriate intervals to ensure their health outcomes were positive. Staff identified opportunities to refer patients to social prescribers (a healthcare professional who connects patients with non-clinical services in their community to help improve health and wellbeing) to improve their quality of life. GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.

There was an effective system in place to review certain health conditions such as asthma and diabetes. The practice website contains information on routine children’s immunisations so patients can see what vaccine is required, at what age and how it is given. The practice did not have an effect process to follow up patients who did not take up the invite for cervical screening.

Patients with long-term conditions had an annual review to check their health and medicines needs were being met. However, the process to increase the uptake of childhood immunisations and cervical screening was not effective. For example, only 60% of people eligible had cervical screening within a set timeframe however, the national expectation was 80%. However, the practice were looking at options to address this such as an open day at the weekend for patients to attend to ask questions and have the procedure if wanted.

We received no specific feedback in this area.

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. They were able to explain how they speak to patients and gain consent. Staff had completed Mental Capacity Act training.

Policies, protocols and guidance were in place to support patients to consent to care and treatment. Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.