Manor Field 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

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. The provider collaborated effectively with the local care home to improve outcomes for residents. The care home praised the effective communication and effective clinical input from the practice. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people and took decisions in people’s best interests where they did not have capacity.

This service scored 79 (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 always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them. For example, our clinical searches identified 11 patients with a potential missed diagnosis of diabetes. We reviewed 5 patient records, which had been individually assessed, with risks explained and documented. We saw how 4 of the 5 patients had been given an appointment to discuss the diagnosis, the remaining patient did not require this appointment.

The service collaborated effectively with the local care home, with 61 occupants that were aligned to the GP practice, to ensure the residents health, care and wellbeing was supported. The practice employed a consultant geriatrician who was responsible for completing ward rounds to the home, focussing on reducing calls to emergency services, the avoidance of unnecessary hospital admissions and competition of ReSPECT forms. Data from the Integrated Care Board (ICB), showed that calls to the emergency services was significantly lower than other homes in the area with a similar number of residents. Data also showed that the care home had significantly fewer 999 calls for falls per number of occupied beds. The practice had also completed the highest number of ReSPECT forms in the local area. The care home manager told us that communication with the surgery was excellent, clinical input was of a high standard and that they provided a high-quality service, which played a key role in supporting the wellbeing of their residents.

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 could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. However, further work was required to ensure that asthma patients were managed appropriately. Searches on the practice’s clinical system highlighted 46 patients with asthma that had been prescribed 2 or more courses of rescue steroids. We looked in detail at 5 patients records and found there was not a consistent follow-up review in place for all 5 patients. Immediately after the assessment the service provided an action plan showing how all 5 patients had been followed up appropriately and there was now a system in place to ensure future patients requiring further review would be followed up within clinical guidelines.

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. Searches on the practice’s clinical system showed that all patients with chronic kidney disease level 4 or 5 had received the required monitoring. Searches also identified that 4 patients with hypothyroidism had potentially not received the required monitoring within the last 18 months, we reviewed all 4 records and found all had been reviewed appropriately.

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.

We saw evidence that the practice had regular meetings which were used to share any changes across the practice. However, some staff members believed that communication could be improved further. Feedback from the aligned care home was very positive, they told us that their queries were dealt with promptly and efficiently.

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 practice identified there was a high prevalence of smokers within the practice population. As a result of this they ran clinics with a healthcare assistant called “swap to stop smoking”.

As part of their Primary Care Network (PCN) the practice could refer patients to a social prescriber who completed 3 monthly cancer reviews alongside specialist MacMillan nurses.

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 met national targets for screening and immunisations. The national target for routine childhood vaccinations is 90%. The World Health Organisation (WHO) recommends a rate of 95% for all routine childhood vaccinations. The most recent data (2023/24) showed the practice had achieved 95.3% in 1 out of 5 routine childhood vaccination age groups and over 90% in 4 out of 5 areas. The national target for cervical screening coverage is 80%. The most recent data (2024) showed that practice had achieved 75.9% for eligible patients aged 25 – 49 years old. They achieved 76.3% for eligible patients aged 50 – 64 years old. A review of the latest data available from the provider showed they were on course to achieve the 80% target for both sets of patients. The provider had developed a questionnaire to be sent to patients who were overdue cervical cancer screening to understand any concerns they might have. As a result of this, the provider had managed to discuss the process and what to expect with patients. This encouraged a number of patients to have the screening that would not have done otherwise.

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.

Data supplied from the local ICB showed that the provider had achieved the highest rate of completed ReSPECT forms. One of the partners at the practice was the ReSPECT lead for Rotherham.