Bay Medical Group

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 in this key question. At our last inspection the practice was rated requires improvement in effective. This was because care and treatment for patients with long-term conditions did not always reflect national guidance, urgent health conditions were not always identified, arrangements to support people nearing the end of their lives did not reflect best practice guidance and childhood vaccination uptake remained below national averages despite the range of work the provider was undertaking to improve this. During this assessment, we found that all the required improvements had been made. Our rating for this key question is good overall.

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.

Feedback from people using the service was usually positive. People felt involved in any assessment of their needs and felt that staff understood their individual and cultural needs.

Staff and leaders were aware of the needs of the local community. Staff could add digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff checked people’s health, care, and wellbeing needs during health reviews.

The practice had systems and processes to keep clinicians up to date with current evidence-based practice. People’s immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.

Staff gave people information and advice about their health, care and support and how they can be as well as possible – physically, mentally and emotionally.

Staff and leaders were encouraged to learn about new and innovative approaches that evidence shows can improve the way their service delivers care.

The provider had systems to ensure staff were up to date with national legislation, evidence-based good practice and required standards. The provider had effective systems 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.

People received care that was coordinated, and everyone worked well together and with people.

Staff felt their ideas about how to improve the service were listened to. Not all staff told us they were able to attend meetings, but most said minutes of meetings were available,and they also received emails to update them.

Partners had no specific feedback on this area.

This was a large practice with a high number of GP partners, salaried clinicians, managers and staff. There was a partnership board, consisting of the executive team and 3 partners, so not all partners were involved in all decisions. There were also partners’ meetings and operational meetings. It was difficult for all teams to be able to meet together so at times not all relevant information was shared.

Staff provided care and support that enabled people to live as they want to, seeing them as a unique person with skills, strengths and goals.

Staff identified people who may need extra support and directed them to relevant services. This included people in the last 12 months of their lives, people at risk of developing a long-term condition and carers.

People were told when they needed to seek further help and what to do if their condition deteriorated. There was an established social prescribing team for adults and children to support people in a holistic way.

People felt that their health was monitored appropriately and explained to them.

Leaders told us how they monitored people’s health and carried out a programme of audits to monitor improvements made. We were provided with examples of audits and projects taking place within the practice.

As part of the inspection a number of set clinical record searches were undertaken by a CQC GP specialist advisor without visiting the practice. The results from the searches demonstrated that although there were some gaps, there were processes in place to monitor people’s care and treatment. This meant that continuous improvements were made to people’s care and treatment.

The results from the clinical searches undertaken were on the whole positive and demonstrated that there were effective approaches to monitor and improve people’s outcomes. However, people with asthma who had been prescribed 2 or more courses of rescue steroids were not routinely followed up after an exacerbation of their asthma.

People received information about care and treatment in a way they could understand and had appropriate support and time to make decisions.

Staff understood the importance of ensuring that people fully understood what they were consenting to and the importance of obtaining consent before they delivered care or treatment.

There were systems and practices to ensure that people understood the care and treatment being offered or recommended. This helped them make an informed decision.