Limestone 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 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.

93% of patients that completed the National GP Patient Survey data agreed that they felt their needs were met during their last GP appointment which was higher than the local average of 88% and the national average of 90%.

People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. 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. A portable hearing loop was available at reception. 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 systems in place to identify people with previously undiagnosed conditions. Our clinical searches identified 6 patients who may have had a missed diagnosis of diabetes. We reviewed these samples and found they had been followed up appropriately.

Care plans and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) records were completed and reviewed regularly. The provider had effective systems to identify people with previously undiagnosed conditions. Systems were in place to identify individuals with caring responsibilities, who were offered an annual review. All patients with a learning disability were invited to attend an annual health assessment and long-term condition reviews were carried out to those patients who were housebound.

There were appropriate referral pathways to make sure that patients’ needs were addressed. We found that staff had the appropriate skills and training to carry out reviews where appropriate.

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.

Our remote clinical searches identified 6 out of 161 patients with hypothyroidism (a condition where the thyroid does not produce enough hormones) who had not received the appropriate monitoring in the last 18 months. We reviewed 5 of these records and found 2 patients had received the appropriate monitoring and 3 people had been recalled.

Our remote clinical search identified 20 patients with asthma who had been prescribed 2 or more courses of rescue steroids in the last 12 months. Of the 5 patients reviewed, we found 4 were appropriately managed. 1 patient was overdue for monitoring, which was appropriately followed up by the practice during the assessment.

Our remote clinical search identified the practice had 58 patients with diabetes who’s latest HbA1c (blood glucose) level was consistently high. We reviewed 5 patients and found all patients had been followed up appropriately.

Overall, we found the remote clinical searches we undertook included reviewing the monitoring of patients with long-term conditions to assess if National Institute for Health and Care Excellence (NICE) recommendations were followed.

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 told us that they had access to the information they need to appropriately assess, plan and deliver people’s care, treatment and support and they had enough information to plan and refer people and receive subsequent results and information following referral. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. For example, engagement with partners and stakeholders as part of the wider NHS 10-year plan for neighbourhood health service. There were systems and processes in place to enable information to be shared between the provider and services to ensure continuity of care. Regular meetings were held with multi-disciplinary teams to ensure care was coordinated effectively.

There were systems and processes in place to enable information to be shared between the provider and services to ensure continuity of care. Regular meetings were held with multi-disciplinary teams to ensure care was co-ordinated effectively.

The Primary Care Network (PCN) helped to support the practice by providing links to First Contact Physiotherapist, Health and Wellbeing Coach, Listening and Guidance, Occupational Therapist, Dietician, Migrant social prescriber, first contact mental health practitioner, Pharmacists and Physician Assistant. People were able to receive co-ordinated care between the practice and the PCN.

Staff were supportive of each other to ensure they had access to the information they needed to appropriately assess, plan, and deliver people’s care and treatment. To ensure staff were able to work together effectively, the practice adopted an open-door policy to encourage staff to speak up so that any queries were resolved to reflect a positive working environment.

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. Patients were encouraged to take an active role in reviewing their health and were given support to recognise changes in their own health and wellbeing. Health promotion material was observed in the practice and further information could be found on their website that supported national priorities and initiatives to improve population health by supporting people.

The practice demonstrated that its approach to health promotion was systematic, targeted and responsive to local need. It operated a layered, inequality-informed prevention model, incorporating repeated recall systems, translation support, personalised patient contact, health promotion events, and coordinated working through the Primary Care Network (PCN). This was further strengthened through migrant social prescribing, strong clinical leadership, and safeguarding processes for children missing immunisations, which demonstrated a proactive, well-coordinated approach to prevention and health improvement.

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 and people’s own expectations.

The practice was performing in line with national averages for bowel, and breast screening. Cervical screening rates were below the national target of 80% uptake with the practice having achieved 60.8% for people aged between 25 to 49 years of age. They had achieved 65.2% target for people aged 50 to 64 years. Childhood immunisation ranges were below in some areas with ranges between 78% and 93%.

The practice were aware that improving engagement with preventative care remained a significant challenge. Leaders demonstrated awareness of the factors impacting uptake, including high levels of deprivation within the practice population, digital exclusion, a transient migrant community and language barriers, all of which affected patients’ ability to engage with screening and immunisation programmes.

The practice had implemented targeted actions to mitigate these challenges. The evidence provided showed that these interventions were effective, with immunisation uptake improving by 6–8% compared with the previous year.

The practice was actively addressing barriers associated with deprivation. This included engagement with migrant social prescribers to support hard‑to‑reach patients, delivering targeted health promotion activity, and taking steps to reduce digital exclusion.

The practice had an established programme of clinical and non-clinical audits and action plans aimed at driving continuous improvement in patient care and operational efficiency. For example, the practice had implemented an audit looking at stroke prevention in atrial fibrillation and lipid optimisation in Secondary Prevention of Cardiovascular Disease (CVD).

The practice worked with the pharmacy team on a pharmacist-led gabapentinoid (such as gabapentin and pregablin used to treat nerve pain) safety audit. They also focused on patients at increased risk from opioid or Z-drug co-prescribing. All patients reviewed received structured consultation and counselling, resulting in direct safety outcomes including opioid dose reduction, opioid cessation and gabapentin cessation where clinically appropriate. The practice also embedded 6-monthly pregabalin pregnancy risk searches, demonstrating proactive risk communication and supporting patients to make informed, safer treatment decisions.

The practice demonstrated sustained, measurable improvement across multiple clinical outcomes, evidencing continuous improvement, effective partnership working, and learning over time. Outcomes improved significantly, including hypertension monitoring (increased from 45% to 75%), vascular disease control (increased from 43% to 83%), secondary prevention monitoring (increased from 55% to 92%), and primary prevention coverage (increased from 86% to 91%). These improvements were achieved through system redesign, including home blood pressure submissions, open-access monitoring, pharmacist-led medication reviews, community pharmacy support, and non-digital access routes.

Overall, the practice demonstrated a evidence-based care model supported by repeated audit cycles, clinical searches, pharmacist-led optimisation, benchmarking, and Primary Care Network (PCN) collaboration. This helped improve outcomes for patients with hypertension, cardiovascular disease, diabetes, and chronic kidney disease (CKD).

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 and were supported by practice policies. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.