Ashville 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 monitored people’s care and treatment and supported them to live healthier lives. 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.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service planned and delivered people’s care and treatment with them, including what was important to them. They did this in line with legislation and current evidence-based good practice and standards. A review of clinical searches identified practice in line with national guidance.

The provider had systems in place to ensure staff kept up to date with evidence-based guidance and legislation. As part of our assessment, we conducted a detailed review of people’s care records. We reviewed the care of people with long-term conditions, including diabetes, asthma, chronic kidney disease and hypothyroidism. Most people we looked at were receiving appropriate follow-up either from the practice or specialist hospital teams. For people with poorly controlled diabetes, there was evidence of follow-up, and the practice used a prescribing pharmacist to help manage people at higher risk.

The practice completed an audit for the care of people prescribed medicines used to support weight loss. This identified that some people had not received all the checks, advice or follow-up they needed. The practice responded by contacting people who had been missed, completing outstanding checks and providing appropriate advice. It also used the learning from this work to consider how it could improve the monitoring of people receiving other weight-management medicines.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

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.

Practice champions supported a range of patient activities, including walking, arts and crafts, men's and women's gym activities and a gardening group. People could self-refer to these activities or be referred by a GP, including where social isolation had been identified. The practice provided an example of a person who had used social prescribing support and experienced a positive outcome.

The practice also identified and supported carers. Carers were coded on the clinical system, were asked about their caring responsibilities at registration and could participate in a monthly carers' group introduced through quality improvement activity. Staff also signposted carers to other services. The practice had taken action to improve support for unpaid carers after identifying that information about local services was limited or out of date. The practice updated its website, and carers register and contacted patients to encourage them to identify themselves as carers. This increased the number of identified carers from around 380 to 433. The practice also worked with patient volunteers and a local carers organisation to introduce a regular carer support drop-in session. This gave carers an opportunity to meet others, share their experiences and access further support.

Staff focussed on identifying risks to people’s health, including those in the last 12 months of their lives and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured outcomes were positive, consistent and met the expectations of people themselves.

However, performance for several preventive health indicators was below expected levels. For example, childhood vaccination uptake included MMR at age 5 of 80.7% against a target of 95%. Cervical screening was 63.3% for people aged 25 to 49 and 71.4% for those aged 50 to 64, against a target of 80%.

The practice recognised challenges associated with its patient demographic and told us about a reduction in nursing hours may have contributed to some lower performance. Although there was evidence of recall and opportunistic education, the data demonstrated further improvements in uptake of childhood immunisations and cancer screening programmes were required.

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