Cambrian 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 Good. At this assessment, the rating remains the same.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Feedback from people using the service was mainly positive. The results of the GP patient survey 2025 showed that 91% of practice respondents felt their needs were met during their last appointment.

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. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. Staff could refer people 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. On the whole, they did this in line with legislation and current evidence-based good practice and standards. The remote clinical searches we undertook of the practice’s clinical records system included reviewing the monitoring of people with long-term conditions to assess if National Institute for Health and Care Excellence (NICE) recommendations were being followed. One of our clinical records searches reviewed the number of patients with asthma who had been prescribed 2 or more courses of rescue steroids in the last 12 months. We identified a total of 107 patients and reviewed a random sample of 5 patient records and found 1 patient had not been followed up appropriately and had not received an adequate annual asthma review. On the day of the site visit, the provider shared a flow chart detailing the expectations for clinicians to follow and undertook to arrange a learning session around the NICE guidance and expectations

For patients with hypothyroidism, our clinical records searches identified 69 patients who had not had thyroid function test monitoring for 18 months. We reviewed a random sample of 5 patient records. From these 5 patient records, we were not assured appropriate monitoring had been undertaken. On the day of the site visit, the practice confirmed that all overdue patients had since been invited for blood tests of which13 of the 69 had already received their blood tests.

Systems were in place to encourage staff to keep up to date with evidence-based guidance and legislation, however we found guidance was not always followed. There was a strong emphasis on learning within the practice and clinical supervision was offered. Several meetings were held to support the sharing of information as well as weekly tutorials arranged for those in training. Staff had access to guidance and medical journals. External meetings and training were also held to share best practice within the primary care network.

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 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. Saturday clinics were held for screening promotions (including cervical screening and tests for identifying prostrate cancer). Staff told us that health promotions during these clinics had resulted in early cancer diagnosis. A range of health promotion information material was available within the practice, including interesting visual displays designed to initiate discussions and raise awareness.

Patients who were referred under the urgent suspected cancer pathway were introduced to a cancer care co-ordinator, who was available to patients for support.

The practice monitored people’s care and treatment to improve it. During our assessment of the service, we noted that the practice had undertaken a number of audits with a view of improving outcomes for patients.

The practice had partly met the national targets for cervical screening (75% of the 80% target). Well woman clinics were held on Saturdays so that working aged women were able to access cervical screening at a time that may be better suited for them.

The practice had met or exceeded the World Health Organisation based target in 4 of the 5 childhood immunisation indicators. The practice had a lead for child immunisation, who was proactive in undertaking searches for children who had not received their scheduled immunisations.

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 checked the records of 5 patients who had a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision on their file. For the files checked, we found that decisions were appropriate. We found that for 1 patient, an incorrect coding had been applied on their records. For another 2 patients, there were no decision forms such as Recommended Summary Plans for Emergency Care and Treatment ReSPECT forms on their records. The practice was very receptive to our findings, and following the inspection, undertook a full audit of the files of all patients living in the community that had a recorded decision of DNACPR (79 patients). A clear plan had been developed for responding to the findings of the audit and clear guidelines in place for when ReSPECT forms were expected to be reviewed.