Wensum Valley Medical Practice West Earlham Health Centre

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 need were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.

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.

Patients told us they had been assessed and received referral to hospital and were followed up appropriately. Patients told us they had received their chronic disease follow up in a timely way and the clinician communicated with them in a way that was easy to understand. However, patient feedback was mixed in respect of clinical teams meeting patients’ needs. A care home representative told us that home visits were on occasions delayed, but also gave an example of prompt care where a suspected urinary tract infection had been promptly acted upon.

Staff told us they prioritised patients who were clinically vulnerable to ensure their needs were assessed and any immediate care and treatment was delivered. This included those patients who may be homeless or those from abroad and recently housed in the area. Leaders and staff told us codes and alerts were added to patient records to ensure patients’ communication, disabilities and any impairment needs were highlighted for staff to tailor patient care. Staff told us, and we saw evidence in clinical records, of clear documentation to support clinicians’ decision making. Patients were made aware of seeking further help if their condition deteriorated. Staff told us they checked patient’s health, care, wellbeing, and communication needs during health reviews.

The systems in place ensured patients’ assessments were up-to-date and staff understood their current needs. Patients experienced appropriate referral pathways to make sure their needs were further assessed and addressed. The practice had systems to identify and prioritise care and treatment for its most vulnerable patients. For example, we saw that all patients with a learning disability were offered an annual health check, and reasonable adjustments were considered to support their attendance to these appointments. The practice held a register identifying patients with caring responsibilities. The practice worked closely with their care coordinator to assist patients to access support from the practice and additional support within the local community. The care coordinator supported with joint home visits with a clinician so patients could be assessed in their home environment when appropriate.

We received direct feedback from patients and reviewed comments submitted to Healthwatch Norfolk. Feedback was mixed. For example, some patients told us that clinicians routinely involved them in decisions about their care and treatment and care home representatives spoke positively about the prompt manner in which a patient was diagnosed and treated. However, we received some feedback from patients about difficulty in accessing appointments.

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. Routine reviews and audits were undertaken to ensure staff were adhering to the most up to date guidelines.

The practice had systems and processes to keep clinicians up to date with and to monitor their use of current evidence-based practice. The minutes of clinical meetings evidence that discussing new guidelines was a standard item on their agenda. The practice systems identified patients and undertook a full assessment of their physical, mental and social needs. There was a system for vaccinating patients with an underlying medical condition according to the recommended schedule. Flu, shingles, pneumonia and meningitis vaccinations were offered to relevant patients. The practice demonstrated that they had a system to identify patients who misused substances, assessed and monitored the physical health of patients with mental illness, severe mental illness, and personality disorder. Patients with poor mental health, including dementia, were referred to appropriate services. GPs followed up patients who had received treatment in hospital or through out of hours services.

We received feedback stating that the whole practice team delivered a positive experience. A patient we spoke with was positive about a prompt hospital x-ray referral and subsequent diagnosis. A Care Home Manager gave an example of where a patient’s suspected infection had been promptly acted upon.

Staff told us they were proud of the cohesive team working relationships they had to ensure all patients received high quality healthcare. They told us they were engaged with the leaders to be innovative and meet their patients’ needs. Staff gave examples of working with other services, so patients were referred, reviewed and supported appropriately. This included work with the people from abroad team, who specialised in supporting patients who were now housed in the area.

We received positive feedback from partners about the way staff and services worked together.

Staff had all the information they needed to deliver safe care and treatment. There were clear policies and procedures in place, and these were easily available for staff to use. 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. Referrals to specialist services were documented, contained the required information and there was a system to monitor delays in referrals.

Patients we spoke with and received comments from gave examples of health checks and long-term condition checks they had received in the previous 12 months.

Staff told us they promoted and encouraged living healthier lives. They recognised that areas of their performance such as cervical cancer screening and childhood immunisations were lower than the national targets. The staff told us they were proactive in identifying the patients concerned and where appropriate contacted them to encourage attendance at appointments. They told us they were flexible with their appointment times to ensure every contact counted. The practice encouraged patients in other lifestyle choices, such as supporting those who wanted to stop smoking and those who need help and support to manage health eating. The innovative group work of the care coordinator, practice staff and the abroad team ensured the population whose first language was not English were encouraged to and provided with the support to live healthier lives.

The practice had systems and processes to ensure patients had access to appropriate health assessments and checks including NHS checks for patients 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. All patients with a learning disability were offered an annual health check. Patients with long-term conditions were offered an effective annual review to check their health and medicines needs were being met.

Patients spoke positively about proactive monitoring (for example being offered regular reviews for their condition). A care home representative told us that acute and proactive care was provided.

Feedback received from staff and leaders was positive about monitoring and improving outcomes. The practice demonstrated a revised recall system for patients to ensure appropriate and timely monitoring. Staff told us the new system in place enabled them to ensure every contact counted and reduced the number of times patients needed to attend the practice. They told us this more cohesive approach to monitoring patients had improved outcomes for patients.

The practice had a comprehensive programme of quality improvement activity and reviewed the effectiveness and appropriateness of care provided. The practice recognised that data indicated that they were performing lower than the national targets for childhood immunisations and for cervical cancer screening. The practice had undertaken detailed audits to ensure they had up-to-date information and had reviewed their processes. They had undertaken detailed reviews of the patients who had not attended and had contacted them. The practice offered a flexible approach to appointments for workers, parents/guardians to book appointments at times that were convenient to them. Clinical staff were proactive to encourage patients to attend their screening appointments and offered flexible booking of appointments including evenings and weekend appointments.

The practice demonstrated they had a comprehensive approach to understanding the performance of the practice in respect of outcomes for patients. 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 and had a proactive approach to positive outcomes for patients. We discussed the practice performance in relation to childhood immunisation and cervical screening. Staff we spoke with described a proactive approach to providing these services whenever the patients contacted the practice. Arrangements were also in place for following up patients when they missed appointments or did not make an appointment were in place. When necessary, the practice would liaise with other agencies including health visitors and school nurses and consult their safeguarding procedures if required. The practice non-clinical team had a system that held up to date information on those that had not attended, which was regularly reviewed and acted on. The leaders and staff explained to us that their patient demographics included patients of many different cultures and languages, and this was a challenge at times to engage patients to attend screening and proactive health reviews. These included patients new to the area, those recently released from prison and those whose first language was not English including Arabic, Farsi, Urdu, Sorani, Russian, Latvian, Lithuanian, Malayalam, Tigrinya, Ukrainian, Pashto, Sudanese, Kurdish, Bandini, Kurmanji and Albanian. The practice offered a flexible approach to appointments including offering Saturday morning appointments. The practice told us they tried to make each contact count and would if appropriate and possible undertake these tasks at any opportunity. The practice employed care coordinator was proactive in reaching out to these patients, ensuring they were able to access appointments and information in a way that was easy for them.

We did not receive any concerns from patients we had feedback from or who we spoke with regarding consent. Care home representatives were positive in their feedback. They told us staff always spoke with the patient, relatives and carers and obtained informed consent taking into account the patients’ choices and decisions.

Staff told us they always obtained consent from patients and offered a chaperone where appropriate. This was recorded on the clinical system. They told us for some procedures written consent was discussed with and obtained from the patient. Clinicians told us they understood these requirements when considering consent and decision making. Clinicians told us they supported patients to make decisions, and where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

The practice had systems and processes in place to obtained consent to care and treatment in line with legislation and guidance. We saw that consent including written consent for some procedures was documented. There were clear systems and processes in place for ensuring patients decisions in respect of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), were made in line with relevant legislation and were appropriate. There was a process in place to ensure DNACPR forms were reviewed when the patient’s condition or circumstances changed.