Mount Road 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 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 79 (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.

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.

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.

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.

A social prescriber employed by the practice provided personalised support for adults and children, carrying out home visits where needed and helping patients overcome barriers to accessing care and community services. Evidence was provided of support for patients with mental health needs, carers and vulnerable individuals, including helping patients attend healthcare appointments, access care packages and engage with community groups. The role was supported through a tracking system to monitor referrals and outcomes. The practice also referred carers for assessments and provided ongoing advice and support.

The practice also undertook a quality improvement project focused on digital inclusion, recognising that digital exclusion can impact a patient's ability to access healthcare services, health information and support. Working collaboratively with its Primary Care Network, the practice identified patients at risk of digital exclusion and implemented initiatives to improve access to digital healthcare tools, including the NHS App. Patients were signposted to local digital support services, community-based training opportunities and digital inclusion events. Outcomes from the project included improved patient contact information records and increased registration for online services. For example, the number of patients identified on repeat medication with no online access to the practice reduced from 418 to 375. This helped patients to access healthcare more independently and effectively.

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.

The practice demonstrated a commitment to monitoring and improving patient outcomes through clinical audit and proactive review processes. Evidence was seen of an ongoing audit of patients prescribed Hormone Replacement Therapy (HRT), led by the Nurse Practitioner. The audit identified 173 patients receiving HRT and was designed to assess whether prescribing remained safe, effective and appropriate. The practice had identified opportunities for service improvement through the audit findings and planned to update its HRT policy and share learning with clinicians once the audit was completed. In addition, HRT monitoring was being incorporated into the practice's monthly recall system to ensure patients receive regular reviews and ongoing assessment of treatment effectiveness and safety.

The service was below national targets for the uptake of childhood immunisations and cervical screening. The practice was aware of the improvements required to the national targets and was attempting to increase uptake. Childhood immunisation uptake was supported through a dedicated administrative staff member who was responsible for follow up of non-attenders, proactive telephone contact from nursing staff and home visits where appropriate. The practice also worked collaboratively with the PCN to promote immunisations and educate patients about health risks such as measles outbreaks. Flexible appointments and extended access were available for cervical screening appointments and patients were sent a link to directly book an appointment online. The practice provided unverified data which showed that they were above target for the year 2025.

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.