Novum Health Partnership

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 a total of 6 quality statements from this key question. The rating for effective at our last inspection was requires improvement. Following this assessment, this key question is now rated as good. We found clinical staff had access to relevant national and local guidelines and used this information to help ensure people’s needs were met. Care was delivered in a coordinated way and took into account the needs of different patients. Clinical staff understood legislation in relation to consent and decision making. Uptake of cervical cancer screening uptake and childhood immunisations were below the national targets. Some patients with long term conditions had not received all necessary monitoring tests. This was in breach of Regulation 12 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patient feedback showed that people felt involved in any assessment of their needs and felt understood by staff. Some patients with long term conditions had not receive the appropriate monitoring tests. This included patients with hypothyroidism and diabetes.

As part of our clinical searches we identified 29 patients with hypothyroidism who had not received the required monitoring tests. We reviewed 5 patients and found 3 patients were overdue medicine reviews. The provider showed us evidence action had been taken to encourage patients to attend for reviews. For example, sending a number of invites using different methods of communication, and reducing the amount prescribed. We reviewed 5 patients with diabetes and found concerns with 4 patients, including raised blood pressure and poorly controlled diabetes. The provider was already aware of these patients and had made attempts to encourage patients to attend for monitoring tests and review.

There were effective systems in place to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

Feedback from patients raised no concerns about delivering evidence based care and treatment.

The practice completed annual reviews for patients with learning disabilities. Meetings were held where the needs of patients receiving palliative care were discussed. Staff were aware of the relevant guidelines to follow when delivering care and treatment.

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 most cases. This included their clinical needs and their mental and physical wellbeing.

Patients told us they were given information on healthy lifestyles by clinical staff at the practice. Patients had access to local community support groups to help people manage long term conditions.

Patients were given advice and information about when and where to seek help should their condition deteriorate. There were systems to ensure information received, such as hospital discharge letters, were handled appropriately and in a timely manner.

The provider had processes to share information with relevant partner organisations, for example safeguarding and palliative care teams.

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.

Patients told us they received healthy living advice, were invited for regular screening tests and had access to health assessments.

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.

There was a health information section on the practice website, which gave advice on different health conditions. There was also a self-refer section where patients could refer themselves for a number of conditions without needing to see a GP. For example, sexual health screening, maternity services, and drug and alcohol support.

Uptake rates for cervical cancer screening and childhood immunisations were below national targets. The number of new cancer cases treated was in line with national averages.

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.

Published results showed the uptake rate for cervical cancer screening was below the 80% target for the national screening programme. Data from June 2023 showed uptake of 62.9%. The provider had taken action to improve uptake rates. For example, they had added additional appointments for cervical cancer screening, made regular contact with patients to encourage bookings and offered education to those hesitant to engage in screening. Uptake rates of childhood immunisations were below the 95% target set by the World Health Organisation (WHO). Data collected from April 2022 to March 2023 was as follows: • 87.2% of children aged 1 had completed a primary course of immunisation for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus influenza type b and Hepatitis B. • 82% of children aged 2 had received immunisation for measles, mumps, and rubella (MMR). • 81.3% of children aged 2 had received immunisation for Haemophilus influenza type b and Meningitis C. • 80.2% of children aged 2 had received their booster immunisation for Pneumococcal infection. • 74.5% of children aged 5 had received immunisations for MMR (2 doses). The provider regularly ran searches to capture patients eligible for immunisations and monitored antenatal discharge letters to contact parents to book appointments. The practice used different methods of communication to contact parents and offered education to those reluctant to engage. Practice staff would opportunistically offer appointments when patients attended the practice for unrelated reasons.

Patients told us they were asked for consent for procedures. Chaperones were routinely offered to patients.

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.

Our review of clinical records showed clear documentation of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) records. We reviewed 3 records; all showed the reviewer had discussed the patient’s current medical conditions and considered the patient’s wishes. Where appropriate, care plans were shared with other organisations.