Grayshott 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, we rated this key question as Requires Improvement. We have seen improvement and at this assessment 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.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

The feedback we received from people who used the service was mostly positive regarding the care they received. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs and we saw evidence to support this. For example, we saw discussions documented within the patient’s clinical record where consideration to an individual’s beliefs had been considered, with clear explanations of how this would impact options for diagnosis and treatment. Staff were aware of the needs of individuals and of the local community. They used digital flags within the patient clinical records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present.

The service had implemented a total triage system to improve access to care for patients. Protocols were in place to support staff in implementing the triage system. For example, we saw there was a home visit protocol which outlined triaging processes for housebound patients.

Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. For example, the service utilised frailty scores generated by their digital system, information about recent hospital admissions and direct GP referral, to inform a regular frailty meeting between the service and the community matron.

The provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation, 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 via regular training updates, professional development activities and supervisory monitoring. Patients’ clinical records we reviewed were well documented, and care had been provided in line with current guidance.

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.

Digital flags were used to highlight patients who were frequent attenders to the service, and the service aimed to provide continuity of care where possible with their usual GP.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The provider 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. 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 that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. A long-term condition care co-ordinator facilitated a comprehensive recall system.

The service had not met all the national targets for screening and immunisations, however leaders in the service were able to describe how they were trying to improve uptake.

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.