The Acorn & Gaumont House Surgery

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

At the last rated inspection, this key question was rated requires improvement. At this assessment the provider demonstrated that improvements had been made. We assessed all quality statements for this key question and found that the service was providing effective services. The provider assessed patient needs in line with best practice guidance, and ensured all staff were aware of the service’s protocols and procedures. The service had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. Staff worked together and worked well with other organisations to deliver effective care and treatment. The service obtained consent to care and treatment in line with legislation and guidance. However, at this assessment we found that the provider had continued to perform below the national target for all key indicators relating to childhood immunisations and cervical screening.

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.

We received no specific feedback in this area.

We undertook a review of patient records at the service and found that guidelines were being followed in the large majority of cases. Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.

The service utilised local and national guidance to determine how patient needs should be addressed.

The national patient survey does not specifically query satisfaction with regards to evidence-based care. We did not interview individual staff during the assessment.

Staff told us they received regular updates from leaders at the service. Where there were changes in process guided by learning at the service, staff told us that they were informed and involved in implementing changes.

Clinical staff had access to relevant national and local guidelines and used this information to help ensure that people's needs were met. The provider monitored that these guidelines were followed. Patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing. Where patients’ needs could not be met by the service, staff redirected them to the appropriate service for their needs. Care and treatment were delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.

We received no specific feedback in this area.

Staff were aware of the need to complete accurate and full records, such that information did not need to be repeated by patients. Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. Care and treatment for patients in vulnerable circumstances was coordinated with other services. There were established pathways for staff to follow to ensure patients’ needs were met.

The service ensured that care was delivered in a coordinated way and took into account the needs of different patients, including those who may be vulnerable because of their circumstances. There were clear and effective arrangements for booking appointments and transfers to other services.

We received no specific feedback in this area.

Staff told us that where appropriate, they gave people advice so they could self-care. Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

The service had referral pathways to help patients live healthier lives, for example smoking cessation. The service also had a social prescriber in place to meet patients’ other social needs. We saw that patients received the support they needed to attend annual health checks.

We received no specific feedback in this area.

Leaders described how they monitored the uptake of patient monitoring for long term health conditions monthly at clinical meetings and compared their results with other practices in their primary care network. Leaders and staff told us that audits were discussed at clinical meetings; this was confirmed in the minutes of the meetings we reviewed.

The practice had a comprehensive programme of quality improvement and used information about care and treatment to make improvements. Staff members had been assigned the role of monitoring the uptake for childhood immunisations and cervical screening and following-up on patients who were overdue.

The provider submitted clinical and management audits, these covered medicines and health condition monitoring, which they had carried out to improve outcomes for patients. Leaders held regular clinical and all staff meetings which monitored patients’ outcomes, where the findings were shared with the local integrated care system. However, the provider continued to perform below the national target for all indicators relating to childhood immunisations and cervical screening

We received no specific feedback in this area.

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

Relevant staff had been provided with training in the Mental Capacity Act. The provider monitored the process for seeking consent appropriately. We reviewed two patients Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions and found they were made in line with relevant legislation and were appropriate.