Wheal Northey Also known as Wheal Northey Site

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 remains good. Staff included people in the assessment of their needs, and support was provided where needed to maximise their involvement. The GP Patient Survey results indicated people 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 felt their needs were met.

Staff were aware of the needs of the local community and spoke at length about the people they support. Staff demonstrated an understanding of the additional support some people may need when attending their appointment such as requiring a translator or longer appointments. Leaders were confident people were triaged appropriately, in a timely manner and saw the right clinician at the right time.

The practice had effective systems to identify when people needed to be referred to other services for care and treatment. There were appropriate referral pathways to make sure peoples’ needs were investigated. Digital flags on patient clinical records highlighted additional support needs. Clinical staff used clinical templates when assessing people’s health. Our clinical searches identified 4314 people on the asthma register and 195 of those people had been prescribed 2 or more rescue steroids (treatment for severe asthma episodes) in the last 12 months. We reviewed 5 patient records and found 3 people had not been reviewed appropriately in line with national guidance including an assessment at the time of prescribing and a review to check the response to treatment. Following our site visit, the practice acted swiftly and implemented a new process to ensure people’s needs were met in a timely manner in the future. 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 routine appointments.

People had no specific feedback in this area.

Clinicians kept up to date with current evidence-based practice and were able to give examples of how they did this. Staff who were responsible for reviewing people with long-term conditions had received specific training. Staff were supported and encouraged to complete further training in their specific areas of interest.

The practice had systems and processes to keep clinicians up to date with current evidence-based practice. Care and treatment were delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools. People with long-term conditions were offered an effective annual review to check their health and medicines needs were being met. Our clinical searches identified 1191 people had a diagnosis of hypothyroidism (a condition where the thyroid does not produce enough hormones). We identified 56 people had not received the required monitoring over the previous 18 months. We reviewed 5 patient records and found all 5 were overdue thyroid monitoring. Following our clinical searches, the practice implemented a new process to ensure monitoring was completed before issuing new prescriptions.

People had no specific feedback in this area.

Staff told us they liked the team working environment and many said it felt like a family. They emphasised the value of working across services and sharing knowledge and experiences to get the best outcomes for people. Leaders welcomed partnership working and attended multi-disciplinary meetings to ensure a joined-up approach to supporting people.

Feedback from partners indicated good working relationships with staff from the practice. When partners raised concerns about people they support to access the practice, they told us they felt listened to and respected ‘the practice will listen to our concerns and treat accordingly’.

People received consistent, coordinated, person-centred care when they moved between services. Regular meetings were held between the practice and other health and social care services to ensure continuity of care. On the day of our site visit, there were 965 incoming clinic documents to process which included the daily download of approximately 500 letters from secondary care providers. The oldest document was 2 weeks old. Care was delivered and reviewed in a coordinated way when different teams, services or organisations were involved.

People had no specific feedback in this area.

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

The practice identified people who may need extra support and directed them to relevant services. This included people in the last 12 months of their lives and people at risk of developing a long-term condition. The practice website contained information and links to other sources of information to support people to make healthier choices. Social prescribers connected people with non-clinical services in their community to help improve health and wellbeing.

People had no specific feedback in this area.

Staff and leaders told us people were reviewed or monitored at appropriate intervals to ensure their health outcomes were positive. Staff identified opportunities to refer people to social prescribers to improve their quality of life. Staff told us they took part in national and local quality improvement initiatives. Staff demonstrated how they were trying to improve the uptake of childhood immunisations and how they would escalate concerns. Staff and leaders were passionate about improving health outcomes for their patient population.

Systems and processes were in place to review certain health conditions such as asthma and diabetes. However, our remote clinical searches identified some people had not been monitored appropriately. Following this being identified, the practice strengthened their processes to ensure people would receive monitoring at the right intervals in the future. The practice website contained links to information on routine children’s immunisations so people could see what vaccine was required, at what age and how it is given.

Our clinical searches identified some people had not had a timely review of their medical condition that required regular monitoring. Following this being identified, the practice told us they had reviewed the people we had identified or invited them in for review. For example, our clinical searches identified 328 people with a potential missed diagnosis of chronic kidney disease stage 3-5. Immediately after we found this, the practice told us they had reviewed 169 people and coded them appropriately. The practice showed us unverified data to evidence they had achieved the expected minimum target of 80% of all eligible people receiving cervical screening within a set timeframe. The practice had met or was slightly below the expected minimum target of 90% for childhood immunisations.

People had no specific feedback in this area.

Staff were able to demonstrate how they spoke to people and gained consent. Clinicians understood the requirements of legislation and guidance when considering consent and decision making. Staff had completed Mental Capacity Act training.

Policies, protocols, and guidance were in place to support people to consent to care and treatment. Clinicians supported people to make decisions.