Cleckheaton Group Practice Also known as St John's House

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

Patients were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in patients’ care for the best outcomes and smooth transitions when moving services. Staff made sure patients understood their care and treatment to enable them to give informed consent. At our last inspection, we rated this key question as good. At this assessment, the rating remains the same.

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.

The service made sure patients’ care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff checked patients’ health, care, and wellbeing needs during health reviews. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The practice planned and delivered patients’ care and treatment in line with legislation and current evidence-based good practice and standards. Clinicians we spoke with told us they used a clinical decision support tool integrated into the clinical system, which allowed easy access to the latest evidence-based guidance resources and templates. In addition, clinical guidance and updates were discussed in clinical meetings and in practice protected time. From a selection of patient records reviewed, we saw that overall patient consultations contained appropriate information and demonstrated that care and treatment was being delivered in a safe way. As part of our assessment, a CQC GP specialist advisor (SpA) conducted a series of remote clinical searches of patient records to assess the practice’s procedures around the management of patients with long-term conditions. For example, asthma, chronic kidney disease, diabetes and hypothyroidism. Overall, we found good management of these patients. We gave feedback to the practice on the quality and detail of medicines reviews and the management of asthma patients on short-acting beta 2-agonists (SABAs) and the practice told us they would review these.

The practice worked well across teams and services to support patients. Staff had access to the information they needed to appropriately assess, plan, and deliver care, treatment, and support. We saw there were systems and processes in place to ensure care was delivered and reviewed in a coordinated way which included local care homes, people receiving end-of-life care and those with a learning disability. There were regular documented multi-disciplinary team meetings. Information was shared with and received from out-of-hours services through their clinical system and there were systems in place to follow-up on information received.

The practice supported patients to manage their health and wellbeing to maximise their independence, choice and control. Staff told us they were committed to promoting and encouraging patients to live heathier lives. They told us they used consultations to opportunistically discuss health choices and provide supporting information. This included encouraging patients to attend health checks and reviews and signposting to support groups and self-help advice. Staff told us they supported national health priorities, initiatives and screening programmes to improve the population’s health, for example, breast and bowel screening. Patients had access to a social prescriber, which helped them improve their health, wellbeing and social welfare by connecting them to community services. We saw the practice website had links to health and wellbeing information. The practice included health events and promotion on noticeboards in their waiting area and organised in-house wellbeing events. The practice signposted patients to the NHS Community Pharmacist Consultation Service, where appropriate.

The practice routinely monitored patient care and treatment to continuously improve it. We saw that the practice had a programme of quality improvement, including clinical and non-clinical audits, to drive improvements in care and treatment. There were patient registers in place, for example, those with a long-term condition and those with a learning disability. The practice operated a recall system to ensure patients were offered appropriate health assessments and checks. Data showed that the practice had met the national target (95%) for childhood immunisations. The uptake for cervical screening was 76% (expected uptake 80%). The practice had systems in place to follow-up those patients who did not attend. There was a system in place to promote national cancer screening programmes, for example, breast and bowel screening. We saw there had been an improvement in uptake since our last inspection. We found 77% uptake for breast screening and 74% uptake for bowel screening. At our last inspection, the practice had been an outlier for the completion of learning disability annual health checks. At this assessment we saw that there had been an improvement, and 51 health checks had been completed out of 62 patients on the learning disability register. Similarly, at our last inspection, we saw that outcomes for patients with severe mental illness (SMI) on the register who had had all health checks completed was 28.4%. We reviewed the practice’s data dashboard provided by the ICB and saw an increase to 51.4% (data up to December 2024).

Clinicians understood the requirements of legislation and guidance around people’s consent to care and treatment, including the assessment of a person’s mental capacity to make a decision. When needed, clinicians supported patients and involved their families, carers and other professionals to make decisions in the person’s best interests, including decisions about Do Not Attempt Cardio- Pulmonary Resuscitation (DNACPR). We reviewed 2 patient records and saw evidence of the patient and their relatives being involved in end-of-life care discussions. We saw Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) care plans were used to record patient wishes regarding care and resuscitation and these were stored in the clinical records. Training records showed that staff had undertaken Mental Capacity Act (MCA), Deprivation of Liberty Safeguards (DoLS), DNACPR and ReSPECT training. Staff were aware of the need to request consent to share records in line with General Data Protection Regulation (GDPR) principles. There was a formal consent form in place for invasive procedures, such as minor surgery.