Friary House 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

This is the first inspection for this service since its registration and change to a new provider with CQC. This key question has been rated as good. We assessed all quality statements in the effective key question.

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.

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.

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. However, patients did not always receive coordinated and person-centred care. We were told by leaders, that the Central Office collated information about patients who required reviews for their long-term conditions. We were told that data was collected to ensure there was capacity to meet the demand from patients responding to text messages requesting they book an appointment. Staff told us this caused several issues with telephone lines being blocked by the increased demand and the number of patients complaining they had been invited to book an appointment when appointment availability was low.

We received 86 responses from patients via our “Give Feedback on Care” website form, 48 responses were negative in regard to how difficult it was to access appointments.

The National GP Patient Survey data showed lower than average results for the overall experience of contacting the GP practice, the results were 49.6% with the target percentage being 67.3%.

Additionally, there was no process for the Central Office staff to communicate with the practice about which patients had been considered for a recall text message and whether this was appropriate for the individual patient. For example, if the patient was digitally excluded or had mental or physical health reasons for being unable to receive communication in this manner.

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. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity.

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.

During our clinical searches, patients with long-term conditions such as asthma, chronic kidney disease (CKD) and hypothyroidism were shown to have been assessed and treated in line with national guidelines. A sample of records reviewed showed these patients were recalled in line with blood monitoring requirements and medicines were reviewed. There was evidence to show comprehensive assessments were carried out.

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.

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.

2

Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent.

Staff reported that there were delays in receiving stock and this impacted on services that could be offered to patients. For example, staff told us in interviews and reported in staff feedback forms, that they often had no supplies of gloves, speculums, tourniquets, wound dressings, vaccines and immunisations (including flu vaccines). Meaning that patients could not be provided with appointments for childhood immunisations, flu vaccines, cervical screening, travel vaccines, routine wound dressings.

The practice had not met the national target of 80% for cervical screening coverage, data from June 2024 showed the practice achieved 61%. This indicator enables a practice to monitor coverage and thus implement interventions to increase uptake where appropriate.

Childhood immunisations data from April 2023 to March 2024 showed the practice had only achieved the target of 90% for 2 out of 4 of the immunisation indicators.

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. We reviewed Do not attempt cardiopulmonary resuscitation (DNACPR) decisions for 3 people and found they were appropriate and were made in line with relevant legislation