Ottershaw 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

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.

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 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 assessment of their needs and felt confident that staff understood their individual and cultural needs. Staff were aware of the needs of the local community and understood the needs and preferences of specific groups. For example, some of their older adult patient population preferred telephone or in-person contact to online systems.

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. All staff had undertaken specific training to better understand the needs of those with learning disabilities and this group was offered health checks every year to identify any new or emerging needs. A register of vulnerable patients was kept and regularly updated, and digital flags within the clinical records system were used to highlight any specific individual needs.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a wellbeing co-ordinator, who maintained a strong link between the practice and the local frailty hub.

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.

As part of our assessment, clinical record searches were undertaken remotely. Results demonstrated care was provided in line with current guidance.

Those with long term conditions (LTCs) were recalled yearly for review using their birth month to indicate when this was due. The practice had seen an increase in those attending for review since this system was introduced in May 2024 and meant that those with multiple LTCs could attend less appointments overall.

Audits carried out by the practice, of care provided to those with asthma and diabetes, had also shown improvements to levels of monitoring and higher levels in achievement of treatment targets. A monitoring system had been introduced by the practice to ensure all elements of diabetes management were completed, with the aim of improving health outcomes for the diabetic patient group.

The practice worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs 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 practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

Some staff working at the practice were employed by the local Primary Care Network (PCN). These staff worked across multiple services, and this made teamwork and sharing of information challenging. Practice meetings were held on alternating days to allow all staff to attend some meetings, and minutes from meetings were shared after, with those unable to attend. The practice also used newsletters and private group messaging to ensure that important information reached relevant staff.

The practice 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.

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.

Since November 2023, the practice had provided health education events every 6 months, which had been well attended. Staff and PPG members had been involved in planning and delivering the events with the aims of ‘empowering patients to prevent disease, encouraging self-care, and recognising red flags’. Topics included diabetes prevention, frailty and menopause, and content had been delivered by specialists from secondary care as well as holistic and lifestyle practitioners. Patient feedback for these events had been very positive and the practice was awarded a certificate of ‘innovation and success’ by Surrey Heartlands ICB for this work. The practice had also used feedback from these events to make improvements to care provision. For example, the practice had created a process to improve education for those requesting blood tests to detect prostate cancer, to ensure they understood the limitations of the test and symptoms of concern.

They also responded to demand for social prescribing at these events by making regular clinics available for patients. Feedback from patients using advice from this service detailed the improvement to their quality of life, from being able to access further benefit payments and support services.

During our assessment we saw information about various community services and support groups displayed in the practice and on the practice website. This included support services for people experiencing domestic violence and for those who had suffered a bereavement.

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.

Clinical audits focused on prescribing safety, medicines management, and health condition monitoring. These were aimed at improving patient outcomes. For example, an audit of hormone replacement therapy (HRT) prescribing, enabled the practice to identify where improvements could be made to keep patients safe. The provider also reviewed uptake rates for childhood immunisations and cervical screening.

Between 1 April 2024 and 31 March 2025, the practice did not achieve all national targets for key childhood immunisation indicators. They recognised scores were below the national targets and had implemented a recall system with calls made to parents or guardians to increase booking of appointments. When children were not brought to booked appointments, nursing staff called to discuss this with the child’s parent or guardian. The practice found that specific communities within the practice population had high levels of vaccine hesitancy and staff had worked with health visitors to increase uptake in these groups.

The practice had also undertaken activity to improve the uptake of cervical screening in the practice population. This included calling patients to invite them to book and making eligible people aware of local partnered services providing screening appointments outside of usual practice hours.

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

We assessed a sample of clinical records for patients who were identified as having a do not attempt cardiopulmonary resuscitation (DNACPR) decision recorded. We found that decisions had been documented appropriately and were completed in line with relevant legislation.

Training in the Mental Capacity Act 2005 was included in mandatory training schedules, to ensure all staff understood their responsibilities when gaining consent or assisting patients with decision making.