Hope 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

Effective – This means we looked for evidence that 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 is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

The service demonstrated how care was based on the latest evidence and good practice. Staff worked with healthcare partners involved in people’s care for the best outcomes and transitions when moving between services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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 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. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The service 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.

Information was shared with staff and other agencies to enable them to deliver care and treatment. Delays in referrals were monitored, and audits were carried out to ensure urgent cancer referrals were actioned.

People’s accessibility and communication needs were recorded in their clinical records. Staff were trained in the care navigation process to ensure people were directed to the most appropriate part of the service. Staff had access to the future care planning templates on the service clinical records system which incorporated checks for people’s wishes, mental capacity and any treatment escalation planning.

The service 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 service standards.

The service had an induction programme for clinical and non-clinical staff which included information for training, appraisal and guidance for providing evidence-based care. Clinical staff had access to local care pathways and prescribing guidelines with the British National Formulary (BNF).

We carried out a remote review of the service’s clinical records system and noted people with long-term conditions were assessed and treated in line with national guidelines, such as people with asthma, diabetes, chronic kidney disease (CKD) and hypothyroidism. A sample of records reviewed showed people were recalled in line with monitoring requirements and medicines were reviewed to ensure care was provided in line with evidence-based guidelines. We also noted there were personalised treatment plans for people with diagnosed long-term conditions, within the records we reviewed to inform future care planning. Staff used clinical templates effectively and adapted care for people with complex needs. The service demonstrated an effective system for updating clinical guidelines and protocols.

The service worked well across teams to support people, particularly when people moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The service worked with other healthcare partners to ensure continuity of care, including where clinical tasks were delegated to other services.

The service worked with stakeholder organisations such as secondary healthcare providers to establish and maintain safe systems of care for people. For example, staff monitored referrals which included correspondence from external professionals involved in people's care.

Furthermore, the service worked with the community mental health team to support vulnerable people through treatment planning as part of a multi-disciplinary team.

The service had a system in place for processing newly registered people’s information and summarising medical records. The service had kept up to date with summarising to ensure accurate information was available for clinicians. There were processes to monitor and manage care when people were moved between services such as after referral to secondary care, or admission to hospital. A review of the service’s clinical system indicated people’s test results, consultant letters and documents were being managed in a timely manner to inform future care and treatment planning.

During our review of the service’s clinical records systems, examples of effective plans for the movement of people across multiple services were noted. Referrals and discharge summaries were managed appropriately and considered people’s individual needs, circumstances, ongoing care arrangements and expected outcomes.

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

The service offered a range of health promotion provisions and supported people to make healthy lifestyle choices. For example, the service had a blood pressure monitoring and Body Mass Index (BMI) station in the waiting area to improve accessibility and empower people to manage their own health. Health promotion information was shared via television screens in the service’s waiting areas which encouraged and supported people to manage their own health, care and wellbeing needs. For example, guidance on how to self-refer to local mental health services.

Staff supported national priorities and initiatives to improve population health such as smoking cessation, weight management, and screening services. In January and March 2025, the service offered additional out of hours stop smoking and smear appointments, both pre-bookable and drop-in to improve uptake. There were also systems to follow up on missed appointments for health checks and vaccinations.

The service employed a social prescriber that connected and supported people with activities, groups and services to improve their health and wellbeing. For example, the service recognised the impact of Parkrun to improve both the physical and mental health of those who participate in it, however the closest Parkrun was in Bath (approximately 10 miles away). This meant it was not easily accessible to those that did not have transport. One of the service’s GP partners therefore created the ‘Five Arches’ Parkrun, which included implementing the core team, raised funds, liaised with landowners, met the requirements and registration with Parkrun and became a run director. This commitment encouraged staff and service users to walk, jog, run, or volunteer at the weekly 5km events. This initiative is a collaboration between the Royal College of General Practitioners (RCGP) and Parkrun UK, which uses Parkrun as a community-based tool aiming to improve physical and mental health and strengthen community connections.

The service worked with the local council to secure an Active Travelsocialprescribing project fund. The aim of the project was to reduce barriers to activity as well as health inequalities whilst improving physical and mental health.  The service used Public Health data across the local area to identify the prevalence of obesity, activity levels and mortalities that were preventable against national averages. The project facilitated those who do little or no physical activity to be able to engage with activity by removing both the practical, financial, and perceived barriers with referral pathways available for people via the GP practice. For example, one to one as well as group activities, teaching people to ride bikes, loan free bikes, working with those with additional needs to access activities. Feedback we received from people regarding the project demonstratedaccessible ways to address obesity and sedentary lifestyles which contributed to supporting multiple health conditions,mental health benefits and addressing the harm from social isolation.

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

The service had a program of quality improvement audit activity and routinely reviewed the effectiveness and appropriateness of the care provided. For example, there was a clear plan for conducting clinical and non-clinical audits. Outcomes and learning were shared with staff to ensure future recommendations were implemented.

Outcomes for people were in line with local and national averages, such as meeting national minimum targets for childhood immunisations and cervical screening. The service regularly monitored Quality and Outcomes Framework (QOF) indicators and demonstrated they had carried out audits to improve clinical quality. For example, the service carried out an audit in relation to the prescribing of medicines that have an anticholinergic effect on frail people due to the risks and side effects these can have for people such as increased risk of dementia. The audit used an Anticholinergic Burden (ACB) score, which is a tool that assesses the negative effect of taking one or more medicines with anticholinergic properties. A higher score, especially 3 or more, is associated with increased risks of cognitive and functional decline, falls and fractures in older adults. The service initially identified the percentage of people aged 75 and older with an anticholinergic burden score of 6 or more was 1.42% in April 2024. The service provided additional education sessions for all clinical staff as well as implementing an additional process to calculate anticholinergic burden scores as part of people’s medicine review. This was to encourage stopping or switching people’s medicines to review outcomes within care and treatment planning. The service carried out a second cycle of the audit in January 2025 and found reductions of anticholinergic medicines prescribed overall. The percentage of people aged 75 and older with an anticholinergic burden score of 6 had reduce to 0.88%.

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

Staff understood the legal requirements around consent. Mental capacity was assessed where appropriate, and consent was recorded accurately in the person’s clinical record. There was evidence of shared decision-making and staff had received training in the Mental Capacity Act. Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR), Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) and Treatment Escalation Plans (TEP) records had also been completed in line with national guidance and were reviewed as required.