Chelsfield 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 inspection, we rated this key question as requires improvement. At this inspection, the rating has changed to good.

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.

We carried out searches on the practice’s clinical record system to review the practice’s management of patients with long term conditions. We reviewed patients with asthma who had been prescribed 2 or more courses of rescue steroids within the last 12 months. Some of these patients were eligible for a steroid card as per National Institute for Health and Care Excellence (NICE) guidance but had not been provided with one. We shared our findings with the provider who subsequently ran an audit on patients prescribed steroids. The provider identified 18 out of 410 patients required steroid cards. We saw evidence that all these patients had been issued with steroid cards, the provider planned to repeat the audit each year.

Patients 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 checked patients’ health, care, and wellbeing needs during health reviews. The provider had effective systems to identify patients with previously undiagnosed conditions. Staff could refer patients 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. 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.

The service worked well across teams and services to support patients. They made sure patients only needed to tell their story once by sharing their assessment of needs when patients moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver patients’ care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The service supported patients to manage their health and wellbeing to maximise their independence, choice and control. The service supported patients to live healthier lives and where possible, reduce their future needs for care and support.

Staff focused 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 was involved in a pilot study for patients with chronic kidney disease. This involved introducing a finger-prick blood test at the GP practice which gave fast results. Healthcare professionals then assessed the patients’ current medicine and, where appropriate, made changes to medicine. This resulted in quicker changes than the previous process which involved a standard blood test requiring analysis at a laboratory. The practice reported improved management of patients with chronic kidney disease, and patients involved in the pilot were positive about the processes.

NHS England data from June 2024 showed the practice had not met targets for the uptake of cervical cancer screening. Screening for eligible patients aged between 25 to 49 years was 75.4% and for patients aged 50 to 64 years was 79.1% (the national target for both groups is 80%). Whilst uptake did not meet national targets, the percentage of patients screened for both age groups was higher than local averages. During our assessment the provider showed us unverified data from their records which showed they are on target for achieving improved results for this year. The provider had processes in place to ensure their register of eligible patients was reviewed regularly and remained accurate. Alerts were placed on patient records so that staff could opportunistically discuss cervical screening with eligible patients when they attended for other matters.

UK Health Security Agency (UKHSA) data for the period of April 2024 to March 2025 showed the practice had met the World Health Organisation (WHO) minimum recommendations of 90% uptake for 3 of the 5 indicators for childhood immunisations. The percentage of children aged 2 who had received Haemophilus influenza type b and Meningitis C booster was 88.6%. The percentage of children aged 5 who had received 2 doses of measles, mumps and rubella (MMR) vaccine was 86.2%. The practice had a system to ensure patients were booked in at the appropriate intervals, and parents were contacted if patients were not brought to appointments.

For both cervical cancer screening and childhood immunisations, reminders were sent in a variety of formats including telephone call, text message, email and letter. Patients who had concerns about either cervical screening or childhood immunisations were offered the opportunity to discuss their concerns with a healthcare professional.

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.