The Old School 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 71 (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 mostly positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and needs.

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 service had effective systems to identify people with previously undiagnosed conditions.

Patients with long-term conditions were offered an effective annual review to check their health and medicines needs were being met. Our clinical searches identified 66 people were diagnose with chronic kidney disease and found 9 of these people had not received the appropriate monitoring. We reviewed 5 of these records and found all were being reviewed and monitored by the local hospital.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber (a non-clinical professional who can link people with local community services to support their health and wellbeing).

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 reviewed demonstrated care was mostly provided in line with current guidance. For example, we found 462 people were diagnosed with hypothyroidism (a condition where the thyroid does not produce enough hormones). Our search identified 1 person had not received the appropriate monitoring in the last 18 months and we saw the service had attempted to contact them to invite them in for monitoring. We reviewed people’s records for poorly controlled diabetes and found they were being appropriately reviewed. However, we also reviewed 5 people’s records for acute exacerbations of asthma and found people were not always prescribed medicine, followed up or reviewed appropriately. Following the on-site visit, the service took immediate action to review these people.

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 results of the 2025 National GP Patient Survey indicated people were confident staff had all the information they required. For example, 82% of responders said they felt the healthcare professional they saw at their last appointment had all the information they needed about the person. This was slightly lower than the local and national averages of 92%.

The service worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. For example, community nurses from the home visiting team carried out regular rounds at local care homes and worked closely with care home staff to ensure people’s needs were met.

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 peoples’ health, including those in the last 12 months of their lives and people at risk of developing a long-term condition.

Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. Posters and leaflets with information designed to support people to make healthier choices were on display in the waiting area. The service’s website contained information and links to other sources of information to support people to make healthier choices and support their lifestyles.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The service had actively participated in projects to increase the uptake of childhood immunisations and cervical screening.

The practice met national targets for childhood immunisations.

Verified data for cervical screening available at the time of this assessment was from June 2024 and showed the service was not meeting the uptake target of 80%. Unverified data provided by the service showed they had exceeded the 80% uptake of cervical screening for eligible people aged 50-64 years old as of March 2026. However, they had not reached the same target with only 66% of eligible people aged 25-29 years old. The service had implemented some steps to improve uptake such as occasional Saturday appointments, direct booking links being sent to people and a new process to follow up people that did not attend their appointment.

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.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff followed policies and processes to support people to consent to care and treatment. Staff had completed training in mental capacity.

However, our review of people’s records showed consent around future planning and resuscitation was not always clearly evidenced. We viewed 5 records and found 2 were missing documentation to indicate if consent or capacity to make a decision was considered. Following the site visit, the service addressed our concerns by updating their training and policy to ensure consent and capacity are recorded clearly.