The Shrubberies Medical Centre

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 monitored people’s care and treatment and supported them to live healthier lives. 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.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

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 people’s health, including those in the last 12 months of their lives and those with caring responsibilities. The lead roles poster demonstrated that the practice had an End-of-Life Lead in place and a palliative care tracker, where it was evident that DNR and other needs were regularly reviewed and updated. The service maintained a carers register and used searches to identify and support carers. At the time of review, 183 carers had been identified. Records showed that 74% of eligible carers had completed an NHS Health Check, 69% had received a seasonal flu vaccination, and 40% had accessed social prescribing support. Staff supported national priorities to improve population health through community health events that promoted preventative healthcare, health checks, lifestyle advice and access to support services. The practice also delivered a diabetes support programme to help patients improve self-management of their condition. Records showed that 1,145 patients had received support through social prescribing services during the review period. The practice analysed local population needs and used multidisciplinary working, social prescribing and care coordination to improve access for vulnerable groups, including older people, children and patients with complex health needs. Health promotion materials and signposting information were observed in communal areas during the inspection. The practice has palliative care patient tracker.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured outcomes were positive, consistent and met the expectations of people themselves.

Quality and outcomes framework (QOF) data for 2025–26 showed the practice achieved 92.0% of available points overall and 98.8% within the clinical domain, consistent with its 98.4% clinical domain achievement in 2024–25. The practice maintained a QOF action plan, which was reviewed monthly at governance meetings. Clinical meeting minutes showed regular discussion of chronic disease management, screening uptake, mental health reviews and coding accuracy to support patient outcomes. A QOF Achievement Report produced on 15 May 2026 confirmed the service exceeded the maximum threshold for both cervical screening indicators and the maximum available points for each. Breast and bowel cancer screening programmes' data were not observed during this assessment to evaluate performance. The service proactively managed patients with long-term conditions through clinical searches, medication monitoring and multidisciplinary working. This included targeted support for patients with asthma, COPD and chronic kidney disease. Quality improvement work improved annual COPD review completion increased from 35.7% in 2021 to 93.4% in 2026. Patients at increased risk of deterioration were prioritised for review, personalised care planning and referral to support services, including social prescribing. The service had effective recall and monitoring systems. An EMIS search completed on 9 June 2026 showed that 79% of eligible patients had received an annual health check during the first 10 weeks of the 2026–27 financial year. A coding audit of 20 patient records found 100% accuracy in the recording of diagnoses, clinical metrics and investigation results, supporting reliable recall and follow-up processes. The practice also used a Future Log system to monitor outstanding actions and follow-up requirements. Quarter 3 COVER data for 2025–26 showed broadly good childhood immunisation uptake. MMR1 coverage at 24 months was 85.3%, all children in the cohort had received MMR1 by the 5-year review, demonstrating an effective recall and catch-up system. Immunisation uptake at the 5-year milestone ranged from 91.7% to 100% across routine childhood vaccination indicators.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.