South Milford 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 between services. Staff made sure people understood their care and treatment to enable them to give informed consent.

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.

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.

Administrative 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.

We carried out a series of clinical searches to assess monitoring and quality of care for certain long-term conditions. 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. Clinical searches showed that 39 patients with chronic kidney disease (CKD) had received relevant monitoring in the last 9 months.

Clinical searches identified 10 patients with a potentially missed diagnosis of diabetes. We looked in detail at 4 patient’s records and found that 2 patients had not had the required reviews and support. After assessment the provider informed us that appointments had been made to review these patients.

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

The practice had recently started offering evening appointments for cervical screening to increase uptake and attendance.

The practice ensured patients with a learning disability received annual health checks and had a dedicated coordinator for support.

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.

Searches on the practice’s clinical system identified 60 patients with diabetes with a HbA1c greater than 75. A review of 3 patients records showed that all had received the required monitoring with good interventions and medicines reviews recorded.

Searches identified 39 patients with asthma who had been prescribed 2 or more courses of rescue steroids. We reviewed 4 patient records and found 3 were overdue review and 1 patient with a detailed asthma review. These patients were immediately booked in for review by the practice.

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 and with other community teams such as district nurses and health visitors. Palliative care meetings were held bi-monthly.

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 worked closely with community services such as the local food bank to act as a collection point. They provided a social prescriber led cancer support package service to help support patients with a new cancer diagnosis.

The practice had a dedicated member of staff who worked with patients with a learning disability and information relating to health screening was provided in easy read formats.

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 cervical screening coverage is 80%. The most recent data (2024) showed that practice had achieved 80.5%. The national target for routine childhood vaccinations is 90%. The World Health Organisation (WHO) recommends a rate of 95% for all routine childhood vaccinations. Those practices achieving this level are considered an example of good practice. The most recent data (2023/24) showed the practice had achieved 95.1% in 1 out of 5 routine childhood vaccination age groups and over 90% in 4 out of 5 areas.

Audits completed by the practice in the last 12 months included missed vaccination opportunities.

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.