Napier Road 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.

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.

People felt involved in assessments of their needs and felt confident that staff understood their individual and cultural needs. Feedback from people about the service reinforced this and people said they felt reassured after visiting.

Reception staff were aware of the needs of the local community. They used digital flags in the care records system to highlight any specific individual needs. For example, people with children were given afternoon appointments to ensure they were able to attend the service after school.

Staff checked people’s health, care, and wellbeing needs during health reviews. For example, the service had a focus on making sure carers had yearly health checks after assessing them as a risk group for the development of long-term health conditions.

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The service had effective systems to identify people with previously undiagnosed conditions. For example, we reviewed 5 records of people with a potential missed diagnosis of diabetes. The records demonstrated that people were being monitored appropriately and that people were provided with relevant clinical management.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber who was available to through the primary care network (PCN).

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 ensured staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance.

Our clinical searches showed that the service was managing care appropriately for people with long-term conditions. For example, people diagnosed with asthma, diabetes, hypothyroidism and chronic kidney disease.

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 service worked with other providers to ensure continuity of care, including where clinical tasks were delegated to other services.

The service maintained registers of people with more complex needs. The service worked with their PCN and associated multidisciplinary teams to identify and support vulnerable people.

People who used the service had access to additional services through the PCN. These included physiotherapy, access to a mental health clinical nurse practitioner, and a social prescriber. Wider information on healthcare services in the local area were available through the service’s web site including a Mental Health and Wellbeing Information Hub.

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 patients at risk of developing a long-term condition and those with caring responsibilities. For example, the service had a special focus on carers and ensured they received a yearly health review to identify their health needs and enhance their wellbeing where possible.

Staff supported national priorities and initiatives to improve population health, including smoking cessation and tackling obesity. For example, the service had literature signposting people to local services across the Gillingham and Medway region in their reception area. Signposting for local services and charities was also available on the practice website.

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 service had a quality improvement programme to help drive improvements in their service. PCN pharmacy staff had a structured approach to long term management and audit activity. It was designed to improve outcomes for people using the service. There was a strong focus on diabetes, asthma, and antibiotic prescribing. A project was also looking at childhood cough symptoms and related clinical management approaches.

The service exceeded national targets for childhood immunisations with 95% uptake compared to the national target of 90% for the most recently published indicators (2024/25). This included the percentage of 5-year-olds who had received both booster immunisations for Measles, Mumps, Rubella (MMR).

The service had achieved 72% uptake for cervical screening for women aged 25-49 and 76% for women aged 50-64. This was below the national target of 80%. The service was aware of this, and staff followed up people who did not respond to invitations. This was done by promoting a self-booking process which could be accessed online, alongside literature to encourage screening appointments.

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. We reviewed 6 records associated with the DNACPR process as part of this assessment.