Aelfgar 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

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Systems were in place to act upon Medicines and Healthcare products Regulatory Agency (MHRA) alerts and other safety alerts. However, our clinical searches identified 3 areas to strengthen. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. When decisions were to be made in people’s best interests, where they did not have capacity, staff engaged a multi-disciplinary approach.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community. Reception staff used 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 maintained a register of patients with a learning disability to ensure they were in receipt of an annual health check. All were supplied with a learning disability user-friendly care plan. Patients had been supported by the same practice-based learning disability champion for over 3 years enabling continuity for the patients and they delivered the health checks and annual reviews.

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. Pathology, cytology and other test results were sent to the clinician who requested them. If the clinician was on annual leave the results went to the clinician deputising for action to ensure timely care and treatment. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The practice planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Systems were in place to act upon Medicines and Healthcare products Regulatory Agency (MHRA) alerts and other safety alerts. However, further follow up action was required in blood pressure monitoring for a particular medicine used to ease an over active bladder and for patients who potentially required co-prescribed medicines to reduce the risk of gastrointestinal complications. We sampled 5 of the 20 patient records who had the potential to be pre-diabetic based on their blood test monitoring. Our clinical searches showed they were currently not in the pre diabetes range but had been. Leaders in discussion agreed the need for the application of a consistent approach.

The practice had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Leaders encouraged staff to raise concerns when things went wrong. During staff meetings, the team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. The documentation reviewed showed a lack of a detailed route cause analysis and risk mitigation, although staff spoken with assured us these were fully discussed in their meetings. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. The practice supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. For example, staff referred patients to smoking cessation and obesity services provided by Staffordshire Everyone’s Health.

The practice routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The practice had exceeded the World Health Organisation (WHO) and national targets for childhood immunisations. From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. The practice had completed a range of audits for quality improvement and evaluated the impact of any improvements made.

The practice told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. The practice completed a minor surgery audit between April 2024 and March 2025 which included an audit on consent. A hundred percent of those sampled had a completed consent form in place.