Sandwich 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

People’s needs were assessed, and their wishes were central to the care, support and treatment they received. Staff worked with people and partner services to coordinate care and improve their experiences of services. Staff identified, reported, investigated and learnt from practices, refining their systems to improve patient experiences and outcomes.

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.

People reported receiving accessible, timely and coordinated care. People told us they felt heard and supported. The doctors knew them as individuals, taking the time to read through their record and understand their individual needs.

Staff explained how patients were asked about their preferred method of communication when they registered with the practice and/or during consultations. Staff identified, supported and considered peoples wider health, care and well-being needs. They achieved this by signposting them or working with partners to support them to access appropriate health and welfare provision.

There were system and processes in place to assess, prioritise and review people’s care. Triage systems and guidance documents were in place and accessible to staff to assist them to identify patient needs and escalate them to clinicians. Where appropriate and possible, staff tried to book people in advance for reviews and monitoring. Patient records were flagged to alert staff to individuals needs and preferences. This enabled staff to identify vulnerable groups and proactively invite them for health checks, such as carers.

People told us they were involved in decisions about their care. People were invited in for regular monitoring and non-attendance was followed up. Staff conducted thorough investigations, made timely referrals and followed up with the patient.

Staff and leaders attended regular clinical meetings and had access to formal clinical supervision and peer support both within the practice and the wider primary care network. Staff told us they valued the knowledge, skills and experience of their clinical colleagues and regularly consulted one another regarding their specialism. Their decisions were reflective of national legislation, evidence-based good practice and required standards.

There were established and effective systems in place to identify, share and embed best practice both within the practice and across the primary care network. Thereby promoting and supporting clinicians to learn and improve patient outcomes. Audits were conducted on clinical practice to check adherence to evidence based good practice such as cancer referrals or safe prescribing.

People told us staff worked across sectors to coordinate their care.

Staff told us they worked closely and regularly with partner services both within health and social care environments. They were committed to supporting people and tried to establish and coordinate their care where appropriate to assist them as they move between services. Staff had access to the information they needed to appropriately assess, plan and deliver people’s care, treatment and support. Consultations were thorough and well documented. Plans for transition, referral and discharge considered people’s individual needs, circumstances, ongoing care arrangements and expected outcomes.

We did not receive any concerns from commissioners or other system partners about safeguarding systems and processes.

There were established and effective systems in place to coordinate the timely and appropriate assessment, review and monitoring of people’s needs to maintain continuity of care. Information was appropriately shared, and tasks delegated on a fully auditable clinical system to ensure oversight of the person’s care. The practice regularly reviewed their prescribing practices with neighbouring practices performance data, for example, promoting and monitoring judicious use of antimicrobials.

People told us staff spoke to them about their broader needs and preferences. They were regularly involved in reviewing and contributing to their care plans. People were provided with helpful educational material and/or signposted to support services to encourage their involvement and ownership of their individual health needs.

Staff told us they supported people to manage their health and wellbeing so they can maximise their independence, choice and control. They achieved this by discussing the persons holistic needs and supporting them and/or signposting them to services. Staff spoke proudly of their positive relationship with dementia awareness services and Age UK (a charity for older people).

There were established and effective systems in place to ensure peoples broader health and social needs were identified and considered. People were referred for education and social activities to improve their understanding of health issues and support them to make better choices. For example, people identified as at risk of developing diabetes, were provided with educational literature to assist them to make informed choices. They were also invited to prevention programmes addressing lifestyle.

People told us they were supported to understand and be involved in the monitoring of their health conditions. They told us they attended regular appointments and/or the health professional would contact them via the telephone to check in with them and assess they progress.

Members of the nursing team specialised the monitoring of long-term health conditions such as asthma and diabetes in partnership with the persons lead clinician. They provided a comprehensive service to people, through their assessment, monitoring and interventions.

There were established and effective systems in place to identify, monitor and mitigate risks to people. The practice reviewed all out of hours, emergency hospital admissions and accident and emergency attendances with those requiring actions referred for discussion at clinical meetings. Systems had also recently been revised to ensure the timely receipt, recording, actioning and review of Medicine and Healthcare product Regulatory Agency alerts overseen by the medicine management lead and supported by the prescribing clerk. Patient outcomes were reviewed formally through the quality outcome frameworks used by local commissioners of healthcare. Clinicians initiated and revisited audits to improve patient outcomes by appropriate coding and monitoring of conditions. Recall systems were established and operated effectively to promote safe practice. We saw patients had been repeatedly contacted by the practice where they had failed to engage with required monitoring for their medication.

Outcomes for people were monitored individually by clinicians providing their care and treatment, through governance searches of their clinical system and collectively through audits and clinical discussions. We checked a sample of clinical records and saw actions identified in clinical meetings had been appropriate recorded and completed to improve patient outcomes.

People told us the healthcare professionals were good at treating them with care and concern. They had access to chaperones for consultations, examinations and procedures. They told us they had confidence and trust in who they saw and their judgements.

Staff told us they received training in understanding and supporting people to make informed decisions. Consent was sought on separate occasions in accordance with best practice. This was prior to some treatments to ensure patients had time to understand, consider and ask questions about the procedure.

The practice had established policies and procedures in place to ensure staff were trained in capacity and consent and observed best practice in recording and delivering care. We checked clinical records and saw staff had appropriately recorded patients consent in their records.