Hill Top Medical 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

We assessed all quality statements for this key question. Our rating for this key question is Good. We found staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

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 had access to a range of staff who supported them in the management of their long-term conditions including annual medication reviews. Eligible patients had access to NHS health checks at the practice and at a local community clinic. People’s health, care and wellbeing needs were checked as part of their review. Patients had access to a hearing loop, disabled parking, a multi faith room and a space for breast feeding. Leaflets and letters could be produced in easy read formats and a range of languages.

Staff told us digital flags were used on patient clinical records to highlight patients who require extra support and those with specific individual needs. Communication needs were assessed, and information requested and electronically documented at the point of the patient registering at the practice. Should the patients’ communication needs change these were updated. There was an interpretation service staff told us they could access in addition to google translate.

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. There were effective systems in place to identify people with previously undiagnosed conditions. The practice identified patients living with moderate or severe frailty. They maintained registers of vulnerable patients including, adult safeguarding, learning disability and autism, palliative care and severe mental health. Practice electronic register audits were maintained in order to monitor, review and improve care and treatment. Pathology and results pathways were established with guidance in place for staff.

Patients with long term conditions who had experienced an acute episode of their condition were sign posted to the lead nurse to arrange a review. There were systems in place to support patients and their carers involvement in care and treatment decisions.

Clinicians told us there was a range of systems, meetings and training events in place to keep them up to date and ensured that care and treatment was delivered following evidence-based guidelines. Staff reported annual and medication reviews were managed by recalls run on patient birthdate month and each clinician had a lead area and was assigned an administrative team member to make the calls and requests for the review of patients with multiple long-term conditions.

Audits were completed to improve the effectiveness of the service provided to patients. The practice reviewed and maintained its processes to ensure there was no discrimination when making care and treatment decisions. Effective systems were in place to keep clinicians up to date with current evidence-based practice.

We received no specific feedback from patients regarding their experiences of how staff teams and services worked together.

Staff were able to describe the practice document workflow and had clear roles and responsibilities. Staff knew who to contact for support and advice. They told us they worked in partnership with a range of health and social care professionals as well as tertiary care providers to meet patients care and treatment needs. These included district nurses, a hospital diabetes consultant, their primary care network and the local health visitor and safeguarding team. Staff told us they could refer patients to initiatives including the Diabetes Prevention Programme.

The local Integrated Care Board (ICB) reported the practice had continued to request support from them to improve outcomes and patient care. They told us the practice had taken on board any suggestions for improvement and had been transparent with sharing both positive and negative feedback they had received with the ICB. The practice currently did not use staff employed by their Primary Care Network (PCN).

Processes were in place to ensure shared care agreements were scanned onto the patient records and medicines clearly documented when prescribed within secondary care. Electronic summary card records were used to share information with the out of hours service provider. The practice had systems in place for the effective management of workflow documents.

Patients had access to health promotion and education to support them to live healthier lives. This was provided in various formats such as workshops and seminars, preventative services such as screening and vaccination programmes as well as during face-to-face consultations. NHS health checks were offered to patients over 40. Patients had access to a social prescriber and a pharmacist who could refer to community pharmacy services as well as self-help groups/advocacy services.

Clinicians told us they were involved in referring patients to initiatives which support individual behaviour change Diabetes Prevention Programme and worked in conjunction with a consultant from the hospital who supported patients with diabetes in the community.

The practice had systems in place that enabled staff to signpost patients to tertiary services such as their social prescriber and to their carer lead. The practice employed a pharmacist, and staff could refer patients to community pharmacy services as well as self-help groups and advocacy services.

We received no specific feedback from patients regarding their experiences of how the practice monitored and improved outcomes.

Clinicians could demonstrate how they identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension. Partners described the patient outcome improvements made since they formed the partnership. This included investigation review and monitoring of patients prescribed specific medicines that had the potential for addiction.

The practice had strengthened their systems to ensure that those patients requiring medicine reviews and ongoing monitoring were actively being reviewed and recalled.

There was evidence that clinical audits were carried out to monitor and improve outcomes for patients. Patients with a learning disability were offered an annual health check. End of life care was delivered in a coordinated way which considered the needs of those whose circumstances may make them vulnerable.

We received no specific feedback from patients regarding their experiences of how the practice ensured patient consent to care and treatment.

Staff told us they had completed training that involved an understanding of consent as well as learning disability and autism awareness training appropriate to their roles. Clinicians shared examples and demonstrated their awareness of how they obtained patient consent for procedures including immunisation and screening procedures. Staff we spoke with demonstrated their awareness of patient consent and told us they documented their responsibilities under the Mental Capacity Act.

The practice maintained a consent policy. The practice no longer offered the regulated activity of surgical procedures.