The Loughton 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. At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

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.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. 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. A hearing loop was available. 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 provider had systems in place to identify people with previously undiagnosed conditions. Care plans and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) records were completed and reviewed regularly. 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. Systems were in place to identify individuals with caring responsibilities, who were offered an annual review. All people with a learning disability were invited to attend an annual health assessment and long-term condition reviews were carried out for those people who were housebound.

There were appropriate referral pathways to make sure that people’s needs were addressed. We found that staff had the appropriate skills and training to carry out reviews where appropriate.

There were systems in place to ensure staff were up to date with relevant legislation, evidence-based practice and required standards. Clinical meetings were in place to keep staff up to date. For clinicians who were unable to attend this meeting in person, minutes were taken and disseminated to all clinicians.

The remote clinical searches we undertook of the practice’s clinical records system included reviewing the monitoring of people with long-term conditions to assess if National Institute for Health and Care Excellence (NICE) recommendations were followed.

As part of our clinical searches, we reviewed the monitoring of people with chronic kidney disease stages 4 or 5, people with hypothyroidism, people with asthma and people with diabetes.

We found that the monitoring for all of these people was in line with National Institute for Health and Care Excellence (NICE) recommendations.

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.

There were systems and processes in place to enable information to be shared between the provider and other services to ensure continuity of care. Regular meetings were held with multi-disciplinary teams to ensure care was coordinated effectively.

A GP partner was co-Clinical Director of the primary care network (PCN). The PCN supported the practice by providing links with pharmacists, paramedics and social prescribers. People were able to receive coordinated care between the practice and the PCN.

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.

Staff focussed on identifying risks to people’s health, including those in the last 12 months of their lives, people 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 and people were encouraged to take an active role in reviewing their health and were given support to recognise changes.

There was a blood pressure monitoring facility in the reception area, which was linked directly to the person’s health record at the practice. The results were automatically assigned to a duty clinician to review, which meant that any results which may be of concern were actioned without delay. We saw that this had resulted in timely diagnosis and treatment for people.

Health promotion material was available in the practice and further information could be found on the practice website that supported national priorities and initiatives to improve population health.

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.

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 practice had an established programme of clinical and non-clinical audits and action plans aimed at driving continuous improvement in patient care and operational efficiency. For example, we saw audits had been completed to improve identification, coding, and follow-up of people with diagnostic HbA1c and to ensure accurate identification, staging, and coding of chronic kidney disease Stage 3–5.

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.