Gnosall Surgery

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• 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 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, welbeing and communication 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. Reception staff were aware of the needs of the local community. 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. 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 or housing difficulties, to a social prescriber.

The provider had effective systems to identify people with previously undiagnosed conditions. There were 10 patients identified by our clinical searches as having the potential for a missed diagnosis of diabetes. We reviewed 5 of the 10 and found these to be satisfactory.

Our clinical searches found of the total number of patients with diabetes and a high blood sugar monitoring result (HbA1c >75mmol/l) was 47 out of 578 patients. We sampled 5 of the records and found these to be satisfactorily monitored and reviewed.

There were 5 patients with hypothyroidism that our clinical searches identified as having the potential for not having had thyroid function test monitoring for 18 months out of 411 patients. We sampled 5 and all had been recalled for monitoring.

The total number of patients with asthma who had been prescribed 2 or more courses of rescue steroids, was 52. We sampled 5 of the 52 records. We found these patients were followed up in exacerbation and prescribed Inhaled corticosteroids and reviewed fully except for one patient nonresponsive to all recalls to date.

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. 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. Clinical records we saw demonstrated care was provided in line with current guidance. For example, the clinical search records we reviewed for people who received treatment following an exacerbation of their asthma demonstrated they were followed up within 48 hours, recalled if they did not respond and had evidence of safety netting advice.

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 service held a continuity of care approach ethos, with GPs having their own patient lists to encourage patient rapport and trust where able. The clinical team had contributed to some bespoke clinical templates and care plans for individualised support. The service provided staff training and development opportunities which included career progression.

The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. A pharmacy was co-located within the practice building, a physiotherapy suite, a minor surgery suite and the locally commissioned health promotion service attended the practice and completed patients NHS Health checks. Patients had access to onsite services such as Health Visitors, mental health practitioners, memory clinic, and a visiting consultant psychiatrist.

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.

The practice monitored, encouraged and recalled patients due their childhood immunisations. However, the verified information available to the Care Quality Commission was for the period 01/04/2024 to 31/03/2025. The clinical staff had clear awareness of non-attenders and had appropriately engaged support from the Health Visiting team. The data showed that 40 of the 46 eligible children aged two had received their Haemophilus influenzae type b (Hib) and Meningitis C (MenC) booster, representing 87% against the national 95% target. For measles, mumps and rubella (MMR) immunisation (one dose), 40 of the 46 eligible children aged two attended during the same period, also equating to 87% against the 95% target. In relation to the pneumococcal booster (PCV booster), 41 of the 46 eligible children attended, achieving 89.1% against the 95% target. The data showed that they had met the two other targets for childhood immunisations for eligible children aged two.

Cervical screening uptake data showed that, as of 30/06/2024, 740 of the 1,040 eligible women aged 25 to 49 years had received an adequate screening test within the previous 3.5 years, representing 71.2% uptake, against a target of 80%. For women aged 50 to 64 years, 660 of the 870 eligible women had received an adequate screening test within the previous 5.5 years as at 30/06/2024. This equated to an uptake rate of 75.9%, also below the 80% target. The practice clinical team reported uptake had improved and the verified data once available would demonstrate the improvement made. The practice held health promotion events and encouraged through their colourful and eye-catching, health promotion boards in reception areas.

Health promotion and improvement outcomes post events held at the practice was evidenced. A cancer screening event was held at the practice in October 2025 between 6 and 8pm for patients. Following this event the findings showed improvement in the uptake of bowel and breast cancer screening uptake. For example, following this event the uptake improved from 67% in quarter 2 of the year to 74% in quarter 3. Breast cancer screening uptake rose from 69% to 81% in the same period.

From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. There was a range of clinical and non-clinical audits completed for quality improvement.

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. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. We randomly sampled a selection of the Recommended Summary Plan for Emergency Care and Treatment form (ReSPECT) forms. We looked at the systems in place to support patients in documenting their preferences supported by family/advocate/carers. A ReSPECT form is a personalised plan created through conversations between the individual, their family, and healthcare professionals, detailing what treatments the person would or would not want in an emergency when they may not be able to communicate their wishes. We identified two points for further consideration. One related to a discussion referenced as having taken place “during the Covid period,” and the other arose from secondary care documentation, where the narrative stated that the individual had capacity, while another section recorded that the individual lacked capacity. The clinician advised that, where appropriate to the individual patient, these matters would be discussed and appropriate actions taken. All the forms we reviewed demonstrated a patient-centred approach.