Chalfont 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 in 2018, we rated this key question as Good. At this assessment, the rating remains the same.

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, wellbeing and communication needs with them.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural 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. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. The provider participated in a locally commissioned service for reviewing long term conditions which included a set of protocols to enable the practice to identify and recall patients for tests and follow up as appropriate. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. The local carers service was onsite once a week to engage with patients and promote support that was available in the community.

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.

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. The practice carried out weekly meetings with a partner practice located within the building to collaborate and discuss complex cases, share updates and provide cross team learning.

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 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 did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The practice was below national targets for screening and immunisations. The practice was aware of this and had put an action plan in place to improve these outcomes which included a dedicated member of staff to liaise with patients and health visitors. The practice worked in partnership with another practice in the building to share resources for this area of work. Referrals were also given for patients to receive a home kit for them to carry out the test themselves and return the results to the practice, so that they would feel more comfortable and help improve cervical screening uptake. 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 a system of audit cycles in place to ensure good outcomes were achieved. This included the review of Chronic Obstructive Pulmonary Disease (COPD) patients to optimise inhaler prescribing. The practice increased the number of patients changed to a single triple therapy inhaler from 51 to 60, improving adherence and reducing environmental impact. Another audit focused on reducing prescribing of oral nutritional supplements (ONS), which resulted in a enhanced prescribing criteria and improved dietetic liaison. Audit results were reviewed in governance meetings and used to inform prescribing protocols, patient reviews, and staff training. Re-audits were scheduled to track progress and ensure sustained improvement.

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.