Crosslands 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 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 practice 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. 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 service 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.

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.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Since introducing patient education programmes, there were measurable improvements in clinical outcomes. For example, the proportion of patients with hypertension without a blood pressure recorded in the previous 12 months reduced from15% to 6.8%, exceeding the PCN target of

The practice 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. End of life care plans were recorded across shared systems, enabling real-time access for ambulance, out-of-hours and secondary care teams.

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. Regular multidisciplinary team meetings brought together health, social care and community professionals to coordinate care for patients with complex needs, supporting anticipatory care and reducing the risk of deterioration.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. They supported people to live healthier lives and where possible, reduce their future needs for care and support. The practice further demonstrated learning through the delivery of targeted educational events. Leaders informed us they used these regular events to target patients that were not engaging with the service and following the events patients’ engagement increased for monitoring. This was reflected in improvements as blood pressure control among black or black British patients improved by over 21% compared with a PCN average of 7.6%, with the next highest practice achieving 9.4%. PPG members also spoke positively about the educational sessions that leaders arranged for patients to further educate them on high blood pressure and asthma.

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. Patients were also supported to access national programmes for smoking cessation, weight management and diabetes prevention.

The practice 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. However, the practice performed below the national targets in relation to childhood immunisations and cervical screening ranges.

Data from UK health security agency showed that childhood immunisations ranges were between 82.3% to 85.9%, (World Health Organisation recommends a rate of 95%) and cervical screening ranges were 67.2% for 25 to 49 year olds and 75.5% for 50 to 64 year olds (both below the national target of 80%). The practice was aware of this and informed us they actively called and recalled patients, they offered a range of appointments including out-of-hours, and the nurse and staff offered opportunistic immunisations and smears. There was no evidence yet in official figures that this had resulted in an improvement in uptake.

The practice told people about their rights around consent and respected these when delivering person-centred care and treatment. Consent was documented, and clinicians supported patients in making informed decisions. Where appropriate, mental capacity assessments were carried out and recorded.

Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. Staff had completed training on the Mental Capacity Act.