Custom House 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 with 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 requires improvement due to the service’s performance in child immunisations and cervical cancer screening. At this assessment, the rating had changed to good overall; however, the service was rated requires improvement in the quality statement ‘monitoring and improving outcomes’ due to continued performance issues in child immunisations and cervical cancer screening.

This service scored 67 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The systems in place ensured patients’ assessments were kept up to date, and staff had a clear understanding of their current health and care requirements. Patients were referred appropriately to ensure further evaluation and support where necessary. The service had mechanisms to identify and prioritise care for its most vulnerable individuals. For example, all patients with a learning disability were offered an annual health check, and reasonable adjustments were considered to support attendance. A register was maintained for patients with caring responsibilities, and the service worked closely with an on-site social prescriber to help them access community-based support. The service ensured care and treatment was effective by regularly reviewing people’s health, wellbeing, and communication preferences. Feedback from patients was positive, as the majority of respondents felt involved in their assessments and confident that staff understood their personal and cultural circumstances. Reception staff were familiar with the local community and used digital flags in the care record system to highlight specific requirements, such as the need for longer appointments or interpreter support. Health reviews included checks on physical and emotional wellbeing, and clinical staff used structured templates to guide holistic assessments. The provider had systems to identify previously undiagnosed conditions, and staff referred individuals with social challenges, such as isolation or housing issues, to a social prescriber.

In addition, the service facilitated social groups that met on-site for tea, cake, and informal conversation, open to isolated patients.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service worked effectively across teams and services to support patients. Staff ensured that people only needed to tell their story once by sharing assessments when patients moved between services.

Staff had access to all necessary information to deliver safe care and treatment. Clear policies and procedures were in place and readily available. Systems for sharing information with staff and external agencies supported safe care delivery. Staff liaised regularly with community teams, including health visitors, and mental health practitioners. The service worked with other services including the Primary Care Network to ensure continuity of care.

The service supported people to manage their health and wellbeing, promoting independence, choice, and control. Staff helped people live healthier lives and, where possible, reduce future care needs.Staff focused on identifying health risks, including for patients in the last 12 months of life, those at risk of developing long-term conditions, and those with caring responsibilities. Staff supported national initiatives to improve population health, such as smoking cessation and tackling obesity.

The service routinely monitored people’s care and treatment to continuously improve it. Leaders used computer software to monitor weekly patient uptake for long-term health condition reviews. Audits were conducted in areas identified for quality improvement, and findings were regularly discussed in clinical team meetings.

The service encouraged people to participate in population screening (such as the cervical screening programme) and families to attend for childhood immunisations in line with the UK immunisation schedule. The most recent 2024 data showed the service’s results for four of the four child immunisation indicators were below 80% with the lowest being 65% out on an expected 95% uptake rate.

The national target of 80% for cervical screening uptake, based on NHS Digital data dated 30 June 2024, had not been met (actual uptake for 25- 49-year-olds: 65%; for those aged 50- 64: 79%). The provider shared its 2025 data, which, although unverified and not directly comparable with nationally validated figures, indicated that the service had improved their performance in child immunisations in two indicators, although they remained below the target overall.

The service implemented a comprehensive approach to improving childhood immunisation uptake by actively tracking each child’s schedule using the CEG APL toolkit and issuing phone reminders to parents and carers to support timely booking. They followed up missed appointments promptly and offered catch-up clinics for children with overdue vaccinations. The service provided multilingual communication to ensure accessibility for families whose first language was not English and promoted immunisation awareness through discussions at regular community events and visible information displays within reception.

Additionally, it strengthened community engagement by collaborating with external partners, including immunisation nurse leads who attended local events to provide advice, as well as outreach through schools, faith leaders, and targeted engagement with asylum-seeking families to encourage uptake. Vaccination specialists also contributed to annual health and wellbeing events, while internal collaboration was supported through ongoing involvement of health visitors in clinical meetings.

Clinicians understood the requirements of legislation and guidance when considering consent and decision-making. Consent was documented, and clinicians supported patients in making informed decisions. Where appropriate, mental capacity assessments were carried out and recorded.

A review of three DNACPR decisions confirmed they were made appropriately and in line with legislation. Relevant staff had completed training on the Mental Capacity Act.