Devon Square 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 assessment in March 2015, we rated this key question as Good. At this assessment, the rating remains unchanged.

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 were effective. They appropriately checked and discussed people’s health and care 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.

Staff and leaders were aware of the needs of the local community. The service offered people the option of contacting the service by telephone, online or walk in.

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 people’s health, care, and wellbeing needs during health reviews. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber (Social prescribing was for people who: have one or more long term conditions; need support with low level mental health issues; are lonely or isolated; have complex social needs which affect their wellbeing). Feedback from people using the social prescribing services was positive.
 

The service always 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. They worked to develop evidence-based good practice and standards.

Clinical staff had access to relevant national and formulary guidance, as well as local policies and guidelines and used this information to help ensure that people's needs were met.

Staff told us they received regular updates from leaders at the service. Where there were changes in process, staff told us that they were informed and involved in implementing changes.

We identified during the clinical searches that there were effective reviews and monitoring of people following receipt of Medicines and Healthcare products Regulatory Agency (MHRA) alerts. For example, those relating to diabetes and high- risk medicines.
 

Staff were aware of the need to complete accurate and full records, so that information did not need to be repeated by people when they moved between different services.

People received coordinated and person-centred care. This included, when they were referred to another service, or after they were discharged from hospital. Care and treatment for people in vulnerable circumstances was coordinated with other services. There were established pathways for staff to follow to ensure people’s needs were met.

Multidisciplinary meetings took place, including all GP services within the Primary Care Network (a group of GP services that work together with other local health and social care organisations to provide integrated services for their communities).

There were clear and effective arrangements for booking appointments and transfers 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 peoples’ health, including those in the last 12 months of their lives, people 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.

People were directed to further information on the NHS website and through support groups. For example, managing diabetes and programmes for maintaining a healthy weight.

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 service had not met the 1 of the 2 national targets for cervical screening of 80% from data published in June 2024. For those people aged 25 to 49 years, the service had achieved 77.1%. The provider was aware of the population of its service and used a computer software system to monitor cervical screening invitations and non-responders. To improve attendance and reduce missed appointments, people with upcoming cervical screening appointments were contacted in advance to confirm they were able to attend and not menstruating, allowing timely rescheduling where necessary.

The service had achieved the average national targets for 4 of 5 childhood immunisations from data published in 2024/25. The service was aware of its population. The service took part in immunisation campaigns and actively promoted these. Information about immunisations were provided in various formats and appointments could be arranged with the nurse to discuss immunisations to help inform people’s decision making.

We evidenced during the clinical searches that there were effective reviews and monitoring of people with long-term conditions. For example, people with hypothyroidism (when the thyroid gland does not make enough thyroid hormones to meet the body's needs resulting in symptoms like tiredness and weight gain) and diabetes.

We found that 3 out of 5 reviewed records for people with chronic kidney disease (CKD) had not been coded. An audit of all CKD diagnoses was underway: 50 records had been checked for coding and guideline compliance, and the rest would be audited by June 2026. Clinical records had been reviewed, identifying 116 patients who were risk-stratified, checked, coded, and scheduled for recall. The provider planned for clinics to run from April 2026, with 12 patients per session and 10 clinics planned to complete coding and reviews by June 2026. Tests were booked where needed and CKD letters revised to improve understanding and reduce anxiety.

The provider submitted evidence of 14 clinical and non-clinical audits, which they had carried out to improve outcomes for people. These covered medicines, medicine monitoring, and monitoring of long-term conditions. Leaders and staff told us that audits were discussed at clinical and staff meetings; this was confirmed in the minutes of the meetings we reviewed, which showed the findings were shared and learning outcomes/changes to practice or policies/procedures were cascaded to staff.

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. Clinicians supported people to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

Clinicians followed legislation and guidance when considering consent and decision making, supporting patients and assessing mental capacity as needed. Staff received Mental Capacity Act training, and the service monitored consent procedures, with people's records showing proper consent including for minor surgeries. Staff emphasised ensuring people understood care and treatments before obtaining consent.

We reviewed Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions for 5 people and found they were maintained in line with relevant legislation. We also saw examples of consent forms being used.