Stanmore House Surgery Also known as Dr Cockrell and Partners

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

This service scored 83 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice always made sure people’s care and treatment was effective by assessing their health, care, wellbeing and communication needs with them. There were systems in place to identify patient’s needs and preferences. For example, people’s specific needs were recorded, such as requirement for a longer appointment or the need for a translator. The practice met the accessible information standard; the practice adhered to people’scommunication preferences. Staff could refer patients with social needs, such as those experiencing social isolation or housing difficulties to a social prescriber within the primary care network. The patient participation group (PPG) were a key asset to the practice, who often spoke to patients to understand their individual needs and informed the practice to ensure this was addressed.

91% of patients that completed the National GP Patient Survey agreed that they felt their needs were met during their last GP appointment and 94%felt the healthcare professional they saw had all the information they needed about them during their last GP appointment.Both scores were above the national average. We received positive patient feedback from our ‘Give Feedback on Care’ process, showing that patients felt that staff went the extra mile to help follow up a patient’s concerns.

The practice 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. Meetings were held to ensure staff were updated with the latest information, guidance and changes within the practice.

The clinical searches we undertook of the practice’s clinical records system showed the monitoring of people with long-term conditions was mostly followed in line with National Institute for Health and Care Excellence (NICE) recommendations. For example, one of our clinical record searches reviewed the number of patients with asthma who had been prescribed two or more courses of rescue steroids in the last 12 months. We identified a total of 52 patients and reviewed a random sample of 5 patient records. 4 out of the 5 patients had not received a timely follow up appointment to check their response to the treatment. The practice acknowledged this feedback and leaders quickly provided evidence that they had updated their policy to ensure patients are followed upappropriately within the set timeframe.

We reviewed monitoring of people with hypothyroidism (when the thyroid gland does not produce enough thyroid hormone that can lead to tiredness and weight gain). A total of 498 patients were identified, and we reviewed a random sample of 5 patient records. Of these 5 patient records, 2 patients were overdue their thyroid monitoring. However, we saw evidence of the practice contacting these patients to arrange a review, but these patients did not respond. The practice has since updated their policy to ensure a more robust formal escalation protocol for non-responders to encourage patients to attend their medication review with the best interests of the patient.

We reviewed patients with chronic kidney disease (CKD) stages 4 or 5. A total of 34 patients were identified, and all patients had the appropriate U+E blood test monitoring in the last 9 months.

We reviewed the monitoring of diabetes care and found that all but 1patient received the appropriate care, in line with legislation and current evidence-based good practice. The one patient that had not had a medication review had been contacted by the practice numerous times. We discussed our findings with the practice, and they took immediate action to address the gaps identified. The practice shared evidence of clinical audits that evidenced improved patient care.

Leaders and staff worked well across teams and services to support patients. Information was shared between teams and services to ensure patients experienced a smooth transition between services without the need to repeat their history.

Staff worked collaboratively with other services to ensure continuity of care to ensure people had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. For example, the practice had strong communication with other agencies such as drug and alcohol services, health visitors, mental health gateway workers, social workers, the palliative care team and neighbourhood team. The practice held many team meetings including regular multidisciplinary team meetings within the primary care network to ensure all teams were up to date with relevant information for patients in the community. To ensure staff were able to work together effectively, the practice adopted an open-door approach to encourage staff to speak up so that any queries were resolved to reflect a positive working environment.

The practice always supported people to manage their health and wellbeing to maximise their independence, choice and control. They encouraged patients to take an active role in reviewing their health and recognise changes in their own health and wellbeing by sharing advice and guidance.

The practice were involved in spreading awareness about mental health to provide support to the community. The practice was able to refer patients with specific health conditions for an ‘exercise referral membership’ at a local gym where patients could be involved in the gym, swimming and exercise classes. A walking group was established by the patient participant group (PPG) for patients and staff to join. This offered an opportunity to improve mental and physical health by keeping active. Patient feedback reflects the positive outcome of this group as patients said the walks were something to look forward too and helped meet other people.

The practice employed a wellbeing lead that contributed to health promotion within the practice. For example, health promotion material was displayed throughout the building and further information could be found on their website that supported national priorities and initiatives to improve population health by supporting people. Each month the wellbeing lead researched the international days and promoted awareness on that topic.We received staff feedback through our ‘Give Feedback on Care’ process that showed that many patients were grateful to have such resources at the practice that encouraged them to prioritise their health.

Findings from the clinical search records indicated that the practice routinely monitored people’s care and treatment to improve and ensure that both clinical and patient expectations were met. At the time of our assessment, the latest published information from the UK Health Security Agency (UKHSA) showed that the practice exceeded the World Health Organisation target of95% for the number of children immunised against various infectious childhood diseases. The latest published information from NHS Digital showed the practice’s uptake for cervical cancer screening for women aged 25 to 49 years old was below the 80% national target and was observed at 75.7%. However, the practice’s uptake for cervical cancer screening for women aged 50 to 64 years old was above the 80% national target and was observed as 83.1%. Staff told us they actively engaged with patients to increase the uptake. For example, they had follow up procedures for non-attenders and patients were contacted with a link demonstrating the importance of cervical screening.

The practice told patients about their rights around consent and respected these when delivering care and treatment. Staff understood and applied legislation relating to consent. Patients received information about care and treatment in a way they could understand. Patient’s capacity and ability to consent was considered and clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.