Cardinal Medical Practice

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 from this key question. Our rating for this key question is Good. At this assessment we found improvements had been made since the previous inspection published May 2022. The practice had strengthened their systems to ensure people who required ongoing monitoring were actively being reviewed and recalled. People’s needs were assessed, and care and treatment was now delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools. Our clinical searches were mostly positive and showed appropriate assessment and monitoring of people with long term conditions. Issues we identified were responded to, actions identified and most had been completed at the time of the on-site inspection to mitigate risk. Staff regularly reviewed people’s care and treatment. Consent was sought appropriately. Staff, teams and services worked together to improve people’s outcomes and support people whose circumstances may make them vulnerable. The practice undertook a range of clinical audits to ensure the quality and safety of people’s care and treatment was effectively monitored to improve outcomes. Staff supported people to live healthy lives, and the uptake of learning disability health checks had improved since the last inspection. The practice continued to encourage people to attend for cervical screening and childhood immunisation, however uptake of some childhood immunisation indicators and cervical cytology screening were below England targets.

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 who used the service was generally positive. People were involved in any assessment of their needs and were confident that staff understood their individual and cultural needs. Care home representatives told us people’s needs were assessed.

Leaders and staff told us codes and alerts were added to people’s records to ensure people’s communication, disabilities and any impairment needs were highlighted for staff to tailor their assessment. Staff told us they prioritised people who were clinically vulnerable to ensure their needs were assessed and any immediate care and treatment was delivered.

The practice had systems and processes in place to identify people’s needs and preferences during the registration process and during ongoing care and treatment. The systems in place ensured people’s assessments were up-to-date and staff understood their current needs. People experienced appropriate referral pathways to make sure their needs were further assessed and addressed. Clinical staff visited people living in care homes weekly to assess and review care and treatment, as needed. The practice had systems to identify and prioritise care and treatment for people who were vulnerable. For example, we saw that all people with a learning disability were offered an annual health check, and reasonable adjustments were considered to support their attendance to these appointments. The practice had a nurse who was a learning disability champion. They offered people with a learning disability continuity and familiarity to encourage engagement and promoted awareness of the needs of people with a learning disability. The uptake of health checks for people with a learning disability had improved from 59% at the previous inspection to 88%. The practice had a system in place to identify people with caring responsibilities People who were identified as carers were coded and an automatic task sent for the person to be contacted and given contact information for Suffolk Family Carers. The practice held a register identifying people who were carers. The practice had 3.1% of their population registered as carers. Information for carers was available in the waiting room at each site.

Most people told us that they were satisfied with the care and treatment that they received, and advice and explanations given by clinicians were informative and useful. Representatives from 3 care homes gave positive feedback regarding the clinical knowledge and skills of staff.

Staff told us that the leaders provided opportunities for them to keep up to date with the current guidelines and changes to evidence-based care and treatment. Staff told us they were able to attend meetings to discuss cases and new guidelines, and minutes of the meetings were available should they need them. Staff told us the continued to improve recall systems for people and worked cohesively to ‘make every contact count.’ For example, a range of alerts were on people’s record, so when they attended for a long-term condition appointment, a health care assistant, nurse and GP worked together to ensure all elements of the persons care and treatment were reviewed. This maximised the use of clinical appointment time and reduced the need for people to attend multiple appointments.

The practice had systems and processes to keep clinicians up to date with and monitor their use of current evidence-based practice. We observed from the clinical searches the service delivered evidence-based care though some recording of risk advice and monitoring processes required review. For example, the follow up of people with asthma who were prescribed emergency steroids. GP partners had identified and had started to review people who were affected, and clinicians had been reminded of the importance of following system alerts. A further search identified 9 people as having a potential missed diagnosis of diabetes. We reviewed the records of 5 people and discussed the findings with the GP Partners. At the site visit, the records of all people showing on the search had been reviewed. People who needed a blood test had been contacted and this had either been completed, booked or was being arranged. We searched for people with chronic kidney disease at stage 4 or 5 who had not had blood monitoring in the last 9 months. 100 people had received the appropriate monitoring and 4 people had not. We received the records of 2 of those 4 people and discussed this with the GP Partners who advised attempts had been made to contact these people, but they had not responded. A welfare check by a paramedic had been booked for 1 person and the other person was not in the country and a reminder had been set up to contact them on their return. The other people identified in the search had since had blood monitoring. No other people were now showing on this search. Another search identified 1161 people with hypothyroidism, of whom 2 had not had blood monitoring for 18 months. 1 person had only recently started the medicine, and the other person was only recently overdue. GP partners confirmed at the site visit a blood test had been requested.

Most of the feedback we received was positive in relation to the knowledge of staff and support people received. This included support from services practice staff worked in partnership with, for example at end of life. Representatives from care homes gave positive examples of how they worked together with practice staff.

Staff were aware of the difficulties of working across 3 sites. However, the majority of staff said they were supported because staff who were multiskilled would support at other sites when needed. Staff gave examples of working with other services, so people were referred, reviewed and supported appropriately. Staff told us regular multi-disciplinary team meetings were held with external agencies where vulnerable people or those receiving end of life care were discussed and actions recorded. The practice worked with a range of partner agencies.

We received positive feedback from partners about the way clinical and non-clinical staff communicated and worked together with them effectively, to support the needs of people who used the service. Practice leaders engaged with other organisations and where things had not worked well or could be improved, they worked together to both review and improve their systems.

Staff had all the information they needed to deliver safe care and treatment. The provider had a General Data Protection Regulation (GDPR) policy in place and safe processes for information sharing. They had a Data Protection Registration Certificate, issued by the Information Commissioner's Office. There were systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. The processes in place enabled staff to liaise regularly with community teams such as community nurses, health visitors and mental health practitioners. Practice leaders and staff worked with a range of external partners, for example, other health and social care professionals and mental health services, to support people with a range of needs. For example, the Diabetes Nurse Specialist attended 1 of the sites on a weekly basis to work alongside practice staff, to assess, monitor and review the care and treatment of people with complex diabetes. Staff attended bi-monthly multi-disciplinary team meetings to discuss people whose circumstances may make them vulnerable. For example, people receiving end of life care. External partners such as community matrons and hospice staff attended.

People received NHS health checks and follow up to any issues which were identified. We received positive comments from some people regarding their positive experience of a cervical screening test. Representatives from care homes told us people received general and specific health checks and clinical staff visited to administer vaccinations.

Staff promoted and encouraged health education and promotion to support people to live healthier lives. They gave examples of information they had given to people during health reviews, and services where people could be referred to, or refer themselves to. This included for example, support with drug and alcohol issues, support groups and social prescribing. Information was also available in the practice sites and on the practice website.

The practice had employed an Access and Digital Care Co-ordinator, whose role included working with the wider team to support public health campaigns and aiding access to digital resources to ensure people who were unable to do this themselves were not marginalised. The practice had systems and processes to ensure people had access to appropriate health assessments and checks including NHS checks for people aged 40 to 74. There were systems to allow appropriate and timely follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified. Arrangements were in place to offer people with a learning disability an annual health check. A range of staff were able to signpost or refer people to other services, for example smoking cessation and weight management.

People who used the service and care home representatives told us they received long term condition checks and were monitored effectively.

Feedback received from staff and leaders was positive about monitoring and improving outcomes. Leaders and staff told us they met regularly to monitor progress across a range of health checks and reviews. For example, learning disability heath assessments, NHS health checks and long-term condition reviews. Work was planned, which included the resource needed to meet people’s needs, for example additional nurse resource for cervical screening being available on Saturdays. Leaders and staff explained the demographic of the people registered at the practice included people of different cultures and who used a range of languages. Although they had arrangements in place to support people, they found it was difficult at times to engage people to attend screening and proactive health reviews. GP Partners had recently engaged with the Integrated Care Board and had plans to collaborate with the community and voluntary sector to provide education and opportunistic vaccination in popular community settings.

Clinical searches showed effective care and appropriate monitoring of people with long term conditions. There was a structured system in place for inviting people in for their long-term condition annual reviews and there were designated administration staff who had oversight of this. Arrangements were in place to follow up people who had not attended. Regular audits of these processes were completed to ensure they were effective. There was managerial oversight of this to ensure appointment capacity was increased as necessary. The practice completed clinical audits to ensure the quality and safety of people’s care and treatment was effectively monitored. We reviewed 2, 2 cycle clinical audits, where changes had been implemented and outcomes for people improved.

As part of this assessment, we ran a suite of clinical searches. From these and the selection of records we reviewed we were assured that the practice prioritised positive outcomes for people. 1 clinical search identified 1951 people with diabetes, of those 291 people had a blood test result which was above the recommended level. We reviewed the records of 2 people and found they had been reviewed and had a care plan in place, and for 1 person they had achieved a significant reduction in their blood level. GP leaders already had oversight of the current plan and actions needed for these people. GP Partners were aware that some areas of their performance such as cervical cancer screening and some childhood immunisations were lower than the national targets. The practice monitored and reviewed uptake and additional appointments were made available for cervical screening when needed, for example, during Saturday clinics. Arrangements were in place to follow up people when they did not respond to invitations or missed their appointment. People could book appointments to discuss with a clinician any concerns they had about childhood immunisation and cervical screening. The practice offered a flexible approach to appointments for people who worked and to parents/guardians to book appointments at times that were convenient to them. Discussions were also held opportunistically. For missed childhood immunisation appointments, when necessary, the practice would liaise with other agencies including health visitors and consult their safeguarding procedures if required. Information was available in the practice sites and on the practice website to encourage uptake.

People told us they were involved in decisions about their care, they were able to ask questions during their consultation and they received an explanation in a way that they could understand. We did not receive any concerns from people which were related to consent to care and treatment. Care home representatives told us staff always spoke with people, their relatives and carers and obtained consent taking into account the person’s choices and decisions.

Clinicians told us they supported people to make decisions, and where appropriate, they assessed and recorded a person’s mental capacity to make a decision. Staff had a good understanding of consent and had received appropriate training including Mental Capacity Act training. Staff told us they always obtained consent from people and offered a chaperone where appropriate. This was recorded on the clinical system.

The practice had systems and processes in place to obtain consent to care and treatment in line with legislation and guidance. People were offered a chaperone, and posters were displayed in the practice sites informing people this was available to them. Staff who carried out chaperone duties were trained for the role and had received a disclosure and barring (DBS) check.