LONGROYDE SURGERY

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• 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.

Patients were involved in assessments of their needs. Staff reviewed assessments taking account of patient’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff had access to training and learning opportunities to support them in their role. However, we found the practice needed to improve their monitoring of patients with asthma and ensure steroid cards were given when required.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

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.

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

As part of this assessment process, patients were invited to share their experiences of the practice, feedback from patients was positive, they told us they felt involved in assessments of their 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 provider had effective systems to identify people with previously undiagnosed conditions.

The practice had a palliative care register, and these patients were supported to make informed decisions about their future. The practice had multi-disciplinary team (MDT) meetings every 6 weeks and new cancer diagnoses were discussed weekly. The reception team held a list of priority patients in case any called.

We also reviewed the clinical records looking at patients with long term conditions. We found the following:

Patients with Asthma who had 2 or more courses of rescue steroids in the last 12 months: There were 509 patients on the practice’s asthma register, of which 42 patients had been prescribed 2 or more courses of rescue steroids. We looked at 4 patient records in more detail, we found that none of these patients had the required steroid card provided to them. We also found that none of these patients had been followed up although some had the required safety netting. After the clinical notes review the practice contacted the required patients to provide steroid cards and book monitoring appointments.

Patients with Chronic Kidney disease (CKD) stages 4 or 5 who have not had the required monitoring in the last 9 months: We identified 21 patients with CKD 4 or 5, of these, 4 had not had the required monitoring. We looked at 2 patient records in more detail and found that these patients were under the Nephrology team at the hospital and monitored by them.

Patients with diabetes who’s latest HbA1C was >75mmol/l: We found there was 337 patients registered as diabetic of which there were 51 patients with a HbA1c of more than >75mmol/l. We looked at 2 records in more detail and found that both of these patients were overdue their annual diabetic review, however they had both received multiple communications from the practice to book in. We spoke to the practice, and they advised us that they were planning to focus on overdue reviews for long term conditions in the coming weeks.

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 practice and standards.

Clinical records we saw demonstrated care was mostly provided in line with current guidance. They put in place clinical protocols based on National Institute for Health and Care Excellence (NICE) guidance. We saw evidence of this for both management of Peripheral vascular disease and guidance for diabetes. These protocols were reviewed annually or when changes needed to be made. The practice held weekly clinical meetings where they discussed any changes in guidance and took appropriate actions.

During the clinical searches carried out by our GP Specialist advisor SpA a review of Methotrexate (a disease-modifying anti-rheumatic drug) was carried out. We identified 18 patients and looked at 5 in closer detail, we found that all 5 patients’ prescription did not state the day of the week the medication was to be taken, in line with Medicines and Health Regulatory Authority Agency (MHRA) guidance. In addition, we found that all 5 patient records did not contain a documented link to the conditions for which the patient was prescribed the medication. After the clinical notes review the practice told us they had reviewed all the patients identified and that the date of administration and linked condition had been added to the records.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation.

The service worked well across teams and services to support people. They made sure they were sharing people’s assessment of needs when they 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.

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 practice had 28 people on their learning disabilities register. Of these, 24 patients had their annual review, the remaining 4 had either opted out or did not respond to any of the practice’s contacts.

The practice had 210 people eligible for NHS health checks and in the last 12 months they had completed 69.

The practice had a process in place to contact patients who had not responded to communication with regards to cervical screening or children who have not been brought to their immunisation appointments. The reception team leader contacted these patients.

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.

The service 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 National GP Patient Survey showed that 82% of patients felt they had enough support from local services or organisations to manage long-term conditions, compared to the national average of 68%.

The practices cervical screening uptake rate as of June 2024 was at 74.2% for women aged 25-49 and at 79.9 % for women aged 50-64. The practice provided us with some unverified data from June 2025 showing an uptake rate of above 90% for both age ranges.The practice had been working in conjunction with the primary care network (PCN) care coordinators to improve uptake rate, as well as utilising opportunistic screening.

The practice had met the 90% minimum uptake rate for all 5 routine childhood vaccinations indicators, including 2 indicators with a World Health Organisation (WHO) recommended uptake rate of 95%.

We spoke to staff who could outline the systems the practice had in place to recall and review patients, and they understood their role in this process.

The practice took steps to encourage patients to attend for cervical screening, for example by sending regular recalls, and through opportunistic screening. Appropriate registers were held to ensure effective monitoring of specific groups such as those receiving palliative care.

The service 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. We saw that Do not attempt cardiopulmonary resuscitation (DNACPR) and Recommended Summary plan for emergency care and treatment (ReSPECT) were made in line with relevant legislation, with input from patients and their carers when necessary.

We reviewed 5 DNACPR/ ReSPECT forms while on site and saw that 3 of these had been completed appropriately, showing a record of the consultation and the decisions made. Before the assessment the practice had identified 2 of these who needed new forms completed as the current forms were not to the correct standard, referrals for this had been made.