Bromleag Care 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 found the service was providing effective care. There were processes in place to ensure outcomes were monitored and improved through the use of clinical audits. There were systems to ensure that care was delivered in a coordinated way with other relevant organisations. We also found some areas for improvement. Patients with asthma who were prescribed rescue steroids did not always receive follow up in line with best practice guidance. Systems did not always ensure proper consent processes were followed in regards to DNACPR decisions.

This service scored 67 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We found no concerns regarding people’s experience of assessing needs.

The service utilised local and national guidance to determine how patient needs should be addressed. We undertook a review of patient records at the service, and found that these guidelines were being followed in the large majority of cases. Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.

The service had policies and protocols in place to ensure that patient needs were assessed, and followed national and local guidelines where required. As part of the assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor, and we found that in the large majority of cases, patient needs were assessed.

Our clinical searches identified patients with chronic kidney disease (CKD) were not always coded as such. This meant that patients with CKD may not receive the necessary monitoring tests. Our clinical searches identified 2 patients who had been prescribed rescue steroids for an exacerbation of asthma. We found that both these patients had not received a follow up in line with best practice guidance.

Staff told us they received regular updates from leaders at the service. Where there were changes in process guided by learning at the service, staff told us that they were informed and involved in implementing changes. However, as part of the assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. We asked clinical leaders about why local and national guidelines were not being followed in managing patients, such as those patients with CKD. The clinical leads were unable to detail why national guidance was not being followed.

Clinical staff had access to relevant national and local guidelines and used this information to help ensure that people's needs were met. The provider monitored that these guidelines were followed. Care and treatment was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable. Patients’ needs were fully assessed in many cases. This included their clinical needs and their mental and physical wellbeing. However, the clinical searches that we undertook showed that in some cases processes were not being followed. For instance, we found that there were 2 occasions in the past 12 months where single patients on the asthma register (65 patients in total on the register) had been prescribed rescue steroids more than once. We reviewed the records of both patients and found that in both cases the patient should be followed up within 2 days but had not been followed up a week later. There is a risk of these patients deteriorating due their asthma and not being seen on time.

Care home staff spoke positively about the ability to contact GPs and that referrals were done in a timely manner.

Staff were aware of the need to complete accurate and full records, such that information did not need to be repeated by patients. Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. Care and treatment for patients in vulnerable circumstances was coordinated with other services. There were established pathways for staff to follow to ensure patients’ needs were met.

Partners told us the provider worked collaboratively with external stakeholders.

The service ensured that care was delivered in a coordinated way and took into account the needs of different patients, including those who may be vulnerable because of their circumstances. There were clear and effective arrangements for booking appointments and transfers to other services.

We found no concerns regarding people’s experience of supporting people to live healthier lives.

Staff told us that where appropriate, they gave people advice so they could self-care. Where patients' needs could not be met by the service, staff redirected them to the appropriate service for their needs.

We found no concerns regarding processes to help support people to live healthier lives.

The provider showed evidence of a clinical audit where outcomes had improved for patients through prescription of vitamin D.

Leaders described how they monitored the uptake of patient monitoring for long term health conditions monthly at clinical meetings and compared their results with other practices in their primary care network. Leaders and staff told us that audits were discussed at clinical meetings; this was confirmed in the minutes of the meetings we reviewed.

The provider submitted clinical and management audits, these covered medicines and health condition monitoring, which they had carried out to improve outcomes for patients. Leaders held regular clinical and all staff meetings which monitored patients’ outcomes, where the findings were shared with the local integrated care system.

We found no concerns regarding outcomes showing that the service was monitoring and improving patient outcomes.

Our review of DNACPR records showed that these documents did not always contain relevant information.

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. We saw that consent was documented in most cases. Clinicians supported patients to make decisions.

Processes in place at the service did not always ensure that proper consent processes were being followed. The service had a large number of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions in place, as the service had a disproportionately high number of older patients. We reviewed 4 of these in detail as part of our assessment. Two of the 4 did not contain relevant information. For example, in one of the records reviewed, there was no DNACPR form on file, although the record was coded as such. Individual patient records contained details of discussions with the patient’s family about the DNACPR, but there was no signed form, and no full record of why a DNACPR would be appropriate.