Castlefields 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 was the first assessment for this service since its registration with CQC. This key question has been rated as Good.

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

Feedback through our Give Feedback on Care service was mostly positive. People told us they had absolute confidence in the clinician; clinicians went above and beyond to make sure they were safe and the care from staff was first class. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. We received some negative comments. People told us follow up processes needed to be strengthened and communication regarding referrals needed to be improved.

Reception staff used alerts 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 well-being needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and well-being. The provider 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.

Our remote searches identified that systems for monitoring the care of people with long-term conditions such as asthma, chronic kidney disease and hypothyroidism were very effective. Whilst systems for monitoring people with diabetes were mostly effective, we identified 1 patient who had not received the required blood glucose monitoring since 2021 but had continued to receive regular prescriptions. Immediately following our assessment, the provider made changes to their recall system to address non-compliance with monitoring.
 

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.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance. For example, the management of people with hypothyroidism or asthma.
 

The service 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. For example, the palliative care team and district nurses when supporting people near the end of their life. Nursing staff worked with staff from the local mental health trust to provide monthly clinics for people with serious mental illness. They also worked closely with the community learning disability nurse to support people with a learning disability.

Staff feedback was very positive about how teams and different staff groups worked together to provide care and treatment.
 

The service supported people to manage their health and well-being 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 focused 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. Nursing staff told us how they referred or signposted people to the most appropriate service to improve health outcomes. For example, smoking cessation or weight loss management. People with potential diabetes were added to the pre-diabetic pathway to ensure they received appropriate monitoring and referred to the Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) course, a free education programme for adults with type 2 diabetes.
 

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 practice mostly met national targets for screening and immunisations. The service had met national targets for childhood immunisation uptake in 4 of the 5 childhood indicators and at 89.3% was just slightly below the national minimum target of 90%. Cervical screening uptake rates in the younger and older cohorts were slightly below the 80% target (UK Health Security Agency - Cover of vaccination evaluated rapidly (COVER) programme 2024-2025). However, subsequent unverified data provided by the provider showed an upward trend of 84% and 85% respectively. We found there were strong systems in place to follow up children who failed to attend for immunisations and women who failed to attend for their cervical screening.

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 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. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. However, a copy of a DNACPR put in place by a hospital was not in place in 1 of the patient records we looked at and the address was incorrect in another record. The provider told us they had added this as an agenda item to be discussed at the next clinical meeting and the process would be reviewed by their palliative care lead.