Waterbeach 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

This means we looked for evidence people had the best possible outcomes because their needs were assessed and care and treatment were provided in line with up-to-date best practice.

At our last assessment with the previous provider, we rated this key question good. At this assessment, the rating has remained good.

The practice placed people at the centre of assessing and planning their care. Staff reviewed assessments regularly to ensure they accurately reflected people's changing communication, personal and health needs. Care was based on latest evidence and good practice. Effective partnership working with healthcare professionals and other agencies helped achieve positive outcomes and ensured continuity of care during transitions between services. Staff made sure people understood their care and treatment to enable them to give informed consent.

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.

People gave positive feedback in relation to how their health was assessed and reviewed by clinicians. Most people we spoke with felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural wishes. Care home representatives told us people were involved in all assessment of people’s care, which included their families and carers, as appropriate. The practice made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

All staff we spoke with were aware of the needs of the local community, which included assessing the health needs of people who were seeking asylum and also people from the travelling community. 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.

Clinical staff used recognised electronic templates when assessing people’s health, care and treatment. The practice had effective systems to identify when people needed to be referred to other services for care and treatment. Staff were able to refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber for support.

Our remote clinical searches identified that patients with asthma who had 2 or more courses of rescue steroids in the last 12 months were not always followed up after an exacerbation of their condition. During the assessment, the practice took steps to address this and provided assurances that they were now following up with patients after an exacerbation in line with guidance and that this had been embedded. The practice provided evidence that there had been no harm caused to patients.

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.

Leaders had established arrangements to ensure that staff maintained their knowledge of current guidance and evidence-based practice. This included regular development sessions, protected learning time and the sharing of relevant information during clinical meetings.

Our review of clinical records indicated that care and treatment was provided in line with current best practice guidance. Staff were able to explain the systems used to identify, recall and review people with chronic conditions at appropriate intervals.

The practice always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

Staff had access to the information required to assess, plan and deliver care and treatment safely and effectively. The practice worked collaboratively with other healthcare services to support continuity of care, including when clinical responsibilities were delegated to external providers. People could also access services through the Primary Care Network (PCN), including physiotherapy, social prescribing and extended access appointments.

The practice maintained an active presence within the local community and participated in initiatives aimed at improving health outcomes, for example a Hepatitis C screening programme and complex wound care clinic.

The practice went above and beyond to support people to live healthier lives. Staff consistently supported people to manage their health and wellbeing, through proactive health promotion, early intervention and personalised support. The practice empowered people to make informed decisions about their health and, where possible, reduce their future care and support needs.

The practice actively engaged with both the Patient Participation Group (PPG) and the wider practice population to improve health outcomes and promote wellbeing. Leaders and clinicians worked with the PPG to deliver a programme of ‘Open Education Evenings’. General practitioners (GP’s) at the practice delivered talks on important health promotion topics. This included presentations about prostate cancer and perimenopause. Both the practice and PPG reported that these sessions led to an increase in people seeking support and booking appointments, which demonstrated the positive impact of the practice’s approach to raising awareness and encouraging people to take an active role in their health.

The practice extended its health promotion work beyond traditional healthcare interventions. Leaders worked with volunteers from East Anglian Air Ambulance to provide CPR and defibrillator training for the local population, this resulted in people having an increased awareness of life-saving skills.

Staff showed a strong focus on identifying risks to people's health and wellbeing, including those in the last 12 months of their lives, patients at risk of developing long-term conditions and people with caring responsibilities. The practice actively supported national priorities to improve population health, including smoking cessation and obesity reduction initiatives. This proactive and preventative approach enabled people to improve their wellbeing and maintain healthier lives.

The practice recognised that performance against national cervical screening targets had not consistently been achieved. Staff were committed to increase uptake and were in the process of reviewing their current processes to identify opportunities to encourage patients to attend.

People aged 40 to 74 are eligible for an NHS Health Check. Of the 1,926 registered patients who met the eligibility criteria, 551 had been offered a health check. While the practice had systems in place to invite eligible patients, uptake remained lower than expected, with 378 patients having received a completed health check. This indicated that further work was needed to strengthen processes and improve engagement.

The practice offered annual health checks to people with a learning disability. The uptake of these checks was 71%, and all eligible patients had been offered an appointment. While this demonstrated a commitment to provide monitoring for people with a learning disability, further efforts were required to encourage people to attend and improve uptake rates.

The practice had appropriate policies and guidance to support staff in seeking and recording consent from adults, children and individuals who either had or lacked mental capacity. Staff understood their responsibilities in relation to consent and delivered care in accordance with relevant legislation and guidance.

Staff had received training on consent and the Mental Capacity Act and demonstrated a good understanding of their legal and professional responsibilities. Clinicians took steps to support patients in making informed decisions. Where required, advocates were involved to help patients participate in decisions about their care and treatment.

Information regarding the availability of chaperones was prominently displayed throughout the premises, and patients could request a chaperone if required.