Updated 31 January 2025
Date of Assessment: 28 May 2025 to 5 June 2025. Newhall Surgery is a GP practice and delivers service to 11,013 people under a contract held with NHS England. We carried out an assessment because the service had not been inspected since 2015. The National General Practice Profiles states that the ethnic make-up of the practice area is 97.1% White, 1% Asian, 1.3% Mixed, 0.4% Black and 0.2% other. The age distribution of the practice population indicates the practice had a higher number of young and older people than the local and national averages and lower numbers of working age people. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 6th decile (10 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained, and the majority of risks had been mitigated. Following our assessment the provider forwarded information confirming action had to been taken address identified risks. Improvements had been made to the systems in place to assess and manage the risk of infection. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes. However, record keeping in relation to prescription stationary needed to improve. The provider forwarded the updated prescription tracker following our assessment.
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those carers, who were important to people, when decisions in people’s best interests were made, where they did not have capacity.
People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. The service had introduced an appointment booking and triage tool for appointments and requests to address issues around access. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. The service was developing the service offered to transgender community and participated in shared care agreements. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. The majority of staff felt supported to give feedback and were treated equally, free from bullying or harassment. However, freedom to speak up processes needed to be strengthened through policies and procedures, including named individuals for staff to share any concerns with. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.
Since the last inspection, the service had made improvements and is no longer in breach of regulation 12.