OHP - College Green Medical Practice

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• 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 carried out an announced assessment of 6 quality statements (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 and Consent to care and treatment) under the effective key question and found: Staff involved people in decisions about their care and treatment and provided them with timely advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this. People and communities had the best possible outcomes because their needs were assessed. Their care, support and treatment reflects these needs and any protected equality characteristics. Services worked in harmony, with people at the centre of their care. Leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of everyday work. Everyone was supported to see what works well and not so well based on indicators of quality. Continuous improvement was always guided by this insight.

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.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual needs. Data from the 2024 National GP patient survey showed that 82% of people completing the survey felt the healthcare professional they saw or spoke to was good at considering their mental wellbeing during their last general practice appointment. This was higher when compared to local and national averages. The practice collected feedback from patients following minor surgery procedures. We saw that feedback was extremely positive with patients commenting they had received an excellent service.

Staff were aware of the needs of the local community. Staff used digital flags within the care records system to highlight any specific individual needs and where reasonable adjustments were needed, such as the requirement for longer appointments or for a translator to be present. Staff checked people’s health, care, and wellbeing needs during health reviews. Staff described the processes they used to invite patients in for their reviews and action they took if patients did not attend. Staff told us that GPs and nurses were trained to offer carer assessments. Carers were offered health checks and signposted to additional services as needed.

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. Carers were asked to identify themselves to reception staff and carer health checks were available. The practice had identified 2% of their practice population as carers. Our record reviews indicated that patients presenting with symptoms which could indicate serious illness were followed up in a timely and appropriate way. Care reviews were thorough including those carried out by GPAs and processes allowed GPAs and non-medical prescribers to identify if concerns needed to be escalated to a GP. Our review of records indicated that in a small number of patients, this process had not been followed. Leaders explained that patients were well known to their GP and risks had been considered before altering treatment; however, they would review their processes further. We saw no evidence of discrimination when staff made care and treatment decisions. Patients were told when they needed to seek further help and what to do if their condition deteriorated. The practice had a palliative care lead and kept a register of patients who were palliative. The register was kept under regular review. Patients on the register had all been assessed and assigned a priority score. Patients were discussed in meetings and/or reviewed accordingly. The practice had processes in place to assess the needs of patients living in care homes. Each care home had a lead GP.

Data from the 2024 National GP patient survey showed that of those people that responded to the survey, 95% felt their needs were met during their last general practice appointment. This was higher than local and national averages. Patient feedback we viewed during this assessment was positive about the service that patients had received.

Staff told us they had access to up to date guidelines. The practice was a training practice for GPs and pharmacists; this helped to ensure their knowledge was up to date. Staff attended training sessions within the practice and external opportunities. Staff worked with specialist healthcare professionals where needed to optimise patient care for example a children’s respiratory nurse.

The practice had systems in place to share new guidelines and updates in clinical care. Non-medical prescribers received clinical supervision. This allowed staff the opportunity to raise questions and for the supervisor to ensure that care and treatment was being delivered in line with guidelines. There was program of audit and quality improvement. This ensured that care was being delivered in line with best practice and led to further improvements. Our record reviews showed that care and treatment was mostly being delivered in line with guidelines. Where we found processes required strengthening we shared this with management. They provided assurances at the time that reduced the level of risk and told us they would be reviewing their processes further.

From patient feedback we viewed we found that patients could get information and advice about their health, care and support and patients felt their care and support was co-ordinated. Data from the 2024 National GP patient survey showed that 97% of people completing the survey felt the healthcare professional they saw had all the information they needed about them during their last general practice appointment.

Staff told us that all staff within the different teams at the practice worked well together. Advice and support was available to staff when it was needed. Staff felt communication had improved over the past 2 to 3 years since the 3 practices had merged. A small number of staff felt communication could be improved further. Staff shared examples of where they had worked together with different teams or external organisations to safeguard patients, improve patient experience and/or optimise care and treatment for patients. Staff tried to ensure continuity in care for patients where possible.

The practice had care coordinators that were a point of contact for care home staff. This meant that care home staff could get support and advice quickly from staff that were familiar with their residents. When care coordinators were on leave, cover was arranged, so that support was always available. When the care home had encountered some issues with practice staff, they worked together with the practice to resolve these problems. A GP and/or pharmacist carried out regular ward rounds at care homes. Care home staff were positive about the ward rounds and described staff as extremely caring and that they worked with residents, their families and care home staff to act in accordance with the residents’ best interests. Care home staff felt listened to.

There were effective processes for managing information flowing from and to the practice from external organisations. There were safety netting processes in place to ensure the safe and effective delivery of care. There were processes in place to support the effective assessment and treatment of patients with more complex needs.

Patients felt supported to manage their health and wellbeing. Patient feedback we viewed was positive about advice and guidance provided by clinical staff. People had care and support that was co-ordinated, and everyone worked well together and with the patient. Data from the 2024 National GP patient survey showed that 90% of people completing the survey felt they have had enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses. This was higher than local and national averages. 82% said the healthcare professional they saw or spoke to was good at considering their mental wellbeing during their last general practice appointment

Staff told us they would offer additional monitoring and treatment where it was indicated to support the overall health of the patient. Staff told us that non-clinical staff (prescription clerks) played an important role in identifying where patients may require further monitoring and then contacting patients to ensure these checks were completed. Patients were signposted to additional external services as needed. Staff told us about projects they were involved in to improve uptake with cancer screening and children’s immunisations. Staff told us that patients had been prioritised for health checks and they were invited in according to their risk category.

There was information on the practice website about support groups and information to support healthier living. The practice displayed information relating to diabetes and dementia on the TV screens on each floor of the practice. However, there was no information for patients about healthy lifestyles, support for other long term conditions, support for carers, sexual health / contraception advice or mental health. Staff told us they would print information out for patients; however, this would rely on the patient asking for the information, which may not always be appropriate. The practice was developing a patient peer support network. They were starting on 27 September 2024 as part of the Macmillan coffee morning to invite all their cancer patients and their carers. This would provide an opportunity to interact with each other and meet their cancer champion, and they would have a guest speaker who would talk about their cancer journey and recovery. They planned to have a representative from Macmillan to talk to their patients about the various available resources and benefits. Their next planned event after this would focus on dementia with support from representatives from the Alzheimer’s Society and the Birmingham Carers Hub. The practice was a safe surgery and had information explaining that people could register regardless of nationality or immigration status and did not have to have identification. We saw that this information was only in English. The practice had appropriate processes in place to invite patients in for their immunisations/cancer screening and health screening. Staff monitored if patients had attended and took action when patients did not attend. At the time of the assessment, the practice did not have an assigned social prescriber. The practice was in the process of arranging a replacement. We saw that audits had been carried out in previous years to monitor the impact of social prescribing as part a patient’s care and treatment plans.

Data from the 2024 National GP patient survey showed that 95% of people completing the survey felt their needs were met during their last general practice appointment. This was higher than local and national averages. We viewed patient feedback from a range of sources and saw that it was mostly always positive about care and treatment received. From minor surgery audit data we viewed for 2023-2024, we saw that patient feedback was extremely positive about the service. All 115 patients completing the patient feedback commented that they were happy with the service.

Staff discussed performance, patient experience and outcomes during clinical meetings and during clinical governance meetings. Through these meetings, staff told us they strived to achieve continuity of care, safe systems and high patient satisfaction. Findings from audits were shared with staff to help identify further areas for improvement. Leaders monitored and acted on information from various sources including patient feedback, clinical audits, complaints and incidents.

There were effective approaches to monitor people’s care and treatment and their outcomes. Leaders could benchmark their performance against other OHP practices. The practice reviewed patient outcomes, including for palliative care patients, to see if they had met patients’ wishes Quality improvement audits and projects allowed the practice to assess quality of care and ensure that continuous improvements were made to people’s care and treatment.

From minor surgery audits for 2023-2024 we saw low post-operative infection rates. Our review of clinical records indicated that patients with long term conditions, mental health diagnosis, learning disability or those with dementia received thorough reviews in line with guidelines.

From patient feedback we viewed, we found that patients understood the consent process and their rights around consent to the care and treatment they were offered. Patient’s views and wishes were taken into account when their care was planned. Staff took a patient’s capacity and ability to consent into account, and involved people in planning, managing and reviewing their care and treatment.

Staff helped patients to understand the care and treatment being offered or recommended and to make an informed decision. Staff gave patients information about care and treatment in a way they could understand and offered appropriate support and time to make decisions. Staff understood the importance of ensuring that people fully understood what they were consenting to and the importance of obtaining consent before they delivered care or treatment. All staff we spoke to reported to have completed appropriate training.

Records we viewed showed that all staff had completed relevant training. Our clinical review of patient records where a do not attempt cardiopulmonary resuscitation (DNACPR) decision had been recorded, identified where possible the patient’s views had been sought and respected. Where necessary, people with legal authority or responsibility made decisions within the requirements of the Mental Capacity Act 2005. This included the duty to consult others such as carers, families and/or advocates, where appropriate. The practice audited whether DNACPR decisions had been recorded correctly.