Moulton Surgery

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• 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. Staff actively involved individuals in assessing their needs and provided support where necessary to enhance their participation. They worked collaboratively with all agencies involved in each person's care to achieve the best possible outcomes and ensure smooth transitions between services. Efforts were made to ensure people fully understood their care and treatment, enabling them to give informed consent. Where individuals lacked capacity, staff involved relevant others such as family members or advocates in decision making processes ensuring actions were taken in the person’s best interests.

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, well being and communication needs with them.

Reception staff utilised alerts within the patient records system to identify individual needs such as the need for longer appointments or interpreter support. During health reviews, staff assessed patients’ overall health, care, and well being needs. The practice had designated leads for specific health conditions who monitored patient registers and coordinated timely reviews. Clinical staff used structured templates during care reviews to address broader aspects of patients' health and well being. The practice had access to a Social Prescriber who supported patients with referrals to other services. Patients who were carers were offered dedicated reviews toensure their own health and well being needs were addressed. We noted that assessments were thoroughly documented, covering both physical and mental health, along with lifestyle guidance. The practice also routinely conducted NHS Health Checks to identify patients at risk of developing diabetes and other health conditions at an early stage. Feedback from people 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.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. Care and treatment plans were regularly reviewed and documented, with systems in place to follow up patients experiencing exacerbation of long-term conditions.

The practice had effective systems in place to ensure staff remained up to date with evidence-based guidance and relevant legislation. Clinical records reviewed confirmed that care was delivered in accordance with current best practice. Updates to clinical guidance were clearly documented and routinely discussed during the practice’s monthly teaching and learning meetings. Relevant information was also shared with appropriate staff to maintain consistency and compliance across the team. There was a strong emphasis on continuous professional development and upskilling staff to ensure care delivery aligned with the latest standards.

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.

The practice had established clear networks with local services and the local community where they supported both the local residents and the university students. Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

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 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. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The service routinely monitored people’s care and treatment to continuously improve it. They worked to ensure that the positive outcomes remained consistent and that they met both clinical expectations and the expectations of people themselves.

Clinical searches carried out showed that the practice had a system in place to ensure that patients that required urgent attention were flagged up and there was always someone available on the day to attend to this. During interviews, staff were aware of their roles in monitoring data which helped improve their outcomes. The practice met national targets for screening and immunisations. From the clinical notes we reviewed, and searches done, 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 understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.