The Firs 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

Patients were regularly assessed, and care and treatment were delivered in line with current legislation and evidence-based guidelines. The practice had a programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. Staff worked together and with other organisations to deliver care and treatment.

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.

The national GP patient survey carried out from January to March 2024 had 90 responses. This found 85% of patients stated the healthcare professional was good at listening to them, and 95% of patients stated they were involved as much as they wanted to be in decisions about their care and treatment. In addition, 95% of patients had confidence and trust in the health care professional they saw or spoke to and 91% of patients said their needs were met. The practice submitted their own unverified survey in July 2023 which had received 278 responses. This found 84% of patients found the healthcare professionals were fairly to very good at treating them with care and concern, and 87% of patients stated they were fairly to very good at listening to them. In addition, 73% of patients described their overall experience of the practice between fairly and very good. We were provided with patient feedback from local Healthwatch they had gathered from social media and the provider website from July 2023 to April 2024, found 37 positive and 10 negative comments. The positive comments covered the booking system, the quality of the practice, and reception staff. The negative comments were regarding practice administration and medicines. CQC did not speak to patients on the days of the assessment.

Leaders explained they reviewed a dashboard weekly and discussed targets as part of the quality and safety group. The practices performance for the year ending in March 2024 demonstrated the practice had met 16 of the 20 targets in the previous year. The areas that required improvements were care plans for adult patients with asthma and the monitoring of diabetes. Leaders explained how patients’ immediate and ongoing needs were fully assessed, and patients’ treatment was regularly reviewed and updated. This included their clinical needs and their mental and physical well being. In addition, how patients presenting with symptoms which could indicate serious illness were followed up in a timely and appropriate way. Staff explained they had a call and recall policy for patients who required chronic disease management, cervical screening tests, childhood immunisations, or those who took certain medicines requiring regular blood tests. Leaders and staff explained that all abnormal blood tests were followed up and they had a protocol for workflow, emails, post and test results in place.

As part of the assessment a number of set clinical record searches were undertaken by a CQC GP specialist adviser. A sample of the records of patients with long-term health conditions were checked to ensure the required monitoring was taking place. We also reviewed a sample of patients records who may have an undiagnosed long-term condition. These searches were visible to the practice. We found the search for patients with the possible diagnosis of diabetes following a blood test result, identified one patient where a diagnosis may have been missed. We reviewed this patient record and found no serious concerns. The search for patients with the possible diagnosis of kidney disease following a blood test result, identified all patients had been diagnosed. We reviewed 5 out of 21 patients who had received the 2 or more courses of rescue steroids and found no concerns. We found patients with chronic kidney disease stage 4 or 5 had their required monitoring in the last 12 months. We reviewed patients with diabetes where there was a slightly abnormal blood result and no concerns. We found most patient medicines reviews had not included a review of their diabetes medicines.

The national GP patient survey carried out from January to March 2024 had 190 responses, 95% of patients had confidence and trust in the health care professional they saw or spoke to and 91% stated their needs were being met. The practice submitted their own unverified survey in July 2023 which had received 278 responses. This found 84% of patients found the healthcare professionals were fairly to very good at treating them with care and concern, and 73% of patients described their overall experience of the practice between fairly and very good. CQC did not speak to patients on the days of the assessment.

Leaders and staff told us the practice had systems and processes to keep clinicians up to date with current evidence-based practice. Staff had access to the National Institute for Health and Care Excellence guidelines, monthly clinical meetings. In addition, staff had protected time to attend training on a Thursday, and also shared learning with other clinicians by instant messaging or at clinical meetings.

Staff discussed patient care at clinical, safeguarding and integrated care team meetings. A review of a sample of patients’ clinical records demonstrated they had received evidence-based care. Staff had completed some clinical audits to ensure they were meeting clinical guidelines. The quality and safety group monitored the practices clinical performance monthly.

We could not collect the evidence to score this evidence category.

The leaders explained that when people received care from a range of different staff, teams or services, it was coordinated, and staff worked collaboratively to understand and meet the range and complexity of people's needs. Clinicians attended monthly Integrated care meetings to discuss patients with complex needs. Shared care agreements were made with secondary care providers regarding the prescribing and monitoring of patient medication. The practice held monthly quality and safety meetings where they reviewed their performance. When a patient was discharged from secondary care into primary care with complex needs the practice would review the patients’ needs and carry out a home visit if appropriate.

Leaders explained they met regularly with multi-agency staff to discuss and improve outcomes for people with complex needs. The staff from local integrated care system stated they did not have any concerns about the practice. The practice was actively involved in their local primary network, where they worked with other practices to improve the local health inequalities.

The practice was informed about patients who had attended any emergency services promptly. The practice had a shared care protocol last reviewed in May 2024, this to outlined the role and responsibilities of the patient, the GP and specialist in prescribing medication that would normally be prescribed in secondary / tertiary care. We reviewed a sample shared care agreements with secondary care and found some were not in place. The leaders explained they were aware of some patients where signed shared care agreements were not recorded in the notes. The practice had a dedicated clinical pharmacist who was regularly contacting secondary care to request the agreements for signing but to avoid interruption to patient treatment, the practice continues to prescribe the medicines on the provision that blood test monitoring was up-to-date and there was evidence that the patients were being regularly reviewed in secondary care. The GP partners were responsible for the overview of specific clinical areas.

The national GP patient survey carried out from January to March 2024 had 90 responses. This found 91% of patients stated their needs had been met. When asked about accessing the practice, 76% stated the experience of contacting the practice was very or fairly good and 90% knew what the next step would be after contacting the practice. The practice submitted their own unverified survey in July 2023 which had received 278 responses. This found 84% of patients found the healthcare professionals were fairly to very good at treating them with care and concern, and 73% of patients described their overall experience of the practice between fairly and very good. CQC did not speak to patients on the days of the assessment.

Staff said patients had access to social prescribers, health and well being coaches, mental health specialist nurses and a local weight loss programme. The practice has been involved in forming its own multi-agency action group, which was made up of health partners, and the local authority. This had delivered GP pop up clinics, which provided access to social prescribers, GPs, pharmacists, dentists, nurses, and local vaccination teams together with over 20 other voluntary, community and social enterprises partners. Staff at the practice engaged with the local community through facilitating or taking part in groups for example, digital exclusion work, young person’s engagement work, a World Cafe and working together. They had also been involved in the implementation of diabetes peer groups where people found support from other patients with similar health conditions.

Posters and leaflets were available to direct patients where to seek further advice. The practice had a list of patients who acted as carers for relatives to enable staff to provide extra support. The practice has been involved in forming its own multi-agency action group, which was made up of health partners, and the local authority. This had delivered GP pop up clinics, which provided access to social prescribers, GPs, pharmacists, dentists, nurses, and local vaccination teams together with over 20 other voluntary, community and social enterprises partners. In addition, a garden project and diabetes poor support group and diabetes group consultations. Staff could refer patients to a weight management clinic. The practice nurses also carried out phlebotomy to enable patients to have their blood tests in their own homes. The practice was working with the local primary care network to develop proactive anticipatory care multidisciplinary meetings, this would help patients to stay independent and healthy for as long as possible at home.

We could not collect the evidence to score this evidence category.

Leaders described how they monitored the uptake of patient monitoring for long term health conditions weekly using a computer software. The leaders and staff told us that audits were discussed at clinical meetings and quality and safety meetings. The leaders explained how they conducted multiple audits which were linked to areas where they felt quality could be improved such as patient group directives and areas where there were complaints.

The provider submitted clinical and management audits, these covered medicines, health condition monitoring, diabetes, opioids, patient consultations, deaths and workflow which they had carried out to improve outcomes for patients. The leaders held monthly quality and safety group meetings which monitored patients’ outcomes, where the findings were shared with the local integrated care system.

The practice submitted evidence to demonstrate they reviewed the uptake of childhood immunisations and cervical screening and took steps to improve their uptake. They provided unverified data from 1 April 2023 to 31 March 2024 to show had achieved over 80% uptake in two of the childhood immunisations, and 76% in one (The world health targets are 90%). In addition, unverified data for cervical screening showed they had achieved an average uptake of 74%. The provider submitted their performance data from 1 April 2023 to 31 March 2024 the practice had carried out patient annual health reviews. For example, 75% of asthma reviews and care plans, 67% of diabetes review and care plans a. Eighty-nine per cent of review of patients with a learning disability and 75% reviews and care plans of patients with a diagnosis of severe mental health.

We could not collect the evidence to score this evidence category.

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. We saw that consent was documented. Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

The leaders submitted a copy of the consent policy and withdrawal of consent forms policy last reviewed in February 2024. We reviewed five patients Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions and found they were made in line with relevant legislation and were appropriate. Most staff had completed mental capacity act training.