The Fairfields Practice

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

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same. This meant people’s outcomes were good, and people’s feedback confirmed this. We saw evidence that staff involved people in decisions about their care and treatment and provided them with advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

People’s needs were assessed including their medical, mental and physical wellbeing. Safety netting advice was provided, and people knew what to do if their condition deteriorated. People were involved in decision making regarding their care and the needs of carers of people using services were met. Staff involved the person to make care and treatment decisions and provided advice and support following evidence-based good practice standards. Staff regularly reviewed people’s care and worked with other services to achieve this. Staff were aware of the needs of the local population and referred people to a social prescribing services as needed.

This service scored 79 (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. Feedback from people using the service was positive, with sixteen people surveyed during our on-site assessment stating that the overall experience of 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.

Digital flags within the care records system were used 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.All staff had completed learning disability and autism training, and people were given longer appointments with both a nurse and doctor to review their complex needs.

People’s care and treatment was planned and delivered, and people were involved in decisions about their care, including what was important and mattered to them, for example, end of life care. This was done 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 mostly provided in line with current guidance.

The service worked well across teams and services to support people. Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. Staff feedback was positive about how they worked together with the service. For example, there was team working across different staff groups to address issues such as follow up of people who failed to attend important appointments. The service worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. People had access to services provided by the primary care network (PCN), including physiotherapy, social prescribers and extended access appointments. Mutual support and learning were shared across the PCN. Referrals to other services were audited to ensure that appointments were created for patients in a timely manner, for example, when patients were referred for suspected cancers. We were assured the practice were engaging with patients and encouraging them to attend cancer screening appointments. The practice regularly held multidisciplinary meetings with community nurses, palliative care nurses and specialist nurses, to review vulnerable patient’s holistic care and treatment.

The service routinely monitored people’s care and treatment to continuously improve it by engaging in audits and quality improvement. The service did not meet national targets for screening cervical cytology which was below the national target of 80%. The practice expressed ongoing challenges to achieve higher uptake rates because of their transient population who lived in the area temporarily or declined because of cultural differences. However, GPs were proactive in promoting uptake by contacting people who had not attended screening, offering them an appointment to discuss the reasons for non-attendance. Evidence supplied by the practice showed the personalised approach led to increased uptake. For example, 12 people who were contacted directly by a GP and had an appointment with them prior to booking all attended their smear appointment. The practice implemented the learning observed by sending text reminders with a GP name, including self-booking links for ease of appointments access.

The service offered flexible appointments, for people and had a robust recall system communicating with people in their own language using interpreters. This included home visits for vaccinations for housebound patients. The practice also had access to the home visiting team for child immunisations. The service had systems in place to monitor attendance and follow up non-attenders for immunisations and vaccinations.

People were supported to live healthier lives through referrals to free health and wellbeing support accessed locally. Data supplied by the practice showed they referred 163 people (2.13% of their patient list) in January and February 2025 to local weight management and smoking cessation services. They were also the highest referrer to the service within their PCN.

The practice had effective processes for recording consent within the medical record and guidance was accessible on the practice’s website. The staff had good knowledge of gaining and assessing consent options, allowing the delivery of person-centred care and treatment which was in the person’s best interest. The service told people about their rights around consent and respected these when delivering person-centred care and treatment. The practice kept records of lasting power of attorney and consent to treatment forms were in place where people had mental capacity. We reviewed three records which showed Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.