The Quarter Jack 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.

Feedback from people using the service was positive. People reported feeling involved in the assessment of their needs and expressed confidence that staff understood their individual and cultural requirements. Staff used digital flags within the clinical records system to highlight specific needs, such as the requirement for longer appointments or the use of a translator.

Staff reviewed people’s health, care, and wellbeing needs during health reviews. Clinical staff used structured templates to support comprehensive reviews of wider health and wellbeing. The provider had systems to identify people with previously undiagnosed conditions. Staff were able to refer people with social needs, such as those experiencing isolation or housing difficulties, to a social prescriber.

People with a learning disability were identified on the service’s clinical system and invited to attend annual health reviews. A dedicated team was responsible for booking these reviews and ensuring health action plans were kept up to date. Health action plans are personalised documents that outline a person’s health and wellbeing needs, support requirements, and goals to help manage their care effectively.

The service made use of the ‘Dorset Care Plan’ to promote joined up and person-centred care. This tool brought together information about a person’s health and social care needs, what they wanted to achieve, and input from professionals. This helped make sure their care was well coordinated across services.

The service provided home visiting services for people who were housebound or living in local care homes, supported by its own internal frailty care team and members of the local ‘Aging Well’ team.

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.

The service demonstrated a strong commitment to delivering safe, effective, and evidence-based care and treatment. Systems were highly effective in ensuring all staff remained up to date with current evidence-based guidance and relevant legislation. Clinical records reviewed as part of this assessment showed care was consistently provided in line with best practice standards.

There was evidence of monitoring for people with chronic kidney disease (CKD) stages 4 or 5, in line with national recommendations.

People with hypothyroidism had received timely and appropriate blood monitoring, and those with diabetes had their HbA1c tests completed within the recommended timeframes for effective disease management. All searches completed in relation to long-term condition monitoring were positive, confirming that care was consistently delivered in line with current clinical guidance.

Immunisations were administered in line with national guidance to at-risk groups, including people with underlying health conditions. Following recent changes to the routine childhood immunisation schedule, the service ensured staff had access to UK Health Security Agency (UKHSA) webinars, publications, and training to stay up to date.

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 individual care, treatment, and support. The service worked closely with other services to ensure continuity of care, including where clinical tasks were delegated to external teams.

A review of the service’s clinical system showed test results were being managed in a timely manner to support future care and treatment planning. There were examples of effective plans for transitioning people across multiple services.

One of the services leaders also serves as the Clinical Director of the local primary care network (PCN), enabling effective collaboration across clinical and non-clinical teams. As part of its health prevention initiatives, the PCN has introduced BP@Home, which the service also adopted. This allows people to record their blood pressure readings in an application, providing the service with live data.

The service held monthly multidisciplinary team (MDT) meetings to discuss vulnerable people requiring care and treatment from different services working together. This included specialists from a local hospice to support end-of-life care and community district nurses. There was a collaborative approach to planning and coordinating care with external teams at the earliest opportunity. The service also worked alongside other stakeholders, such as the community health visiting team, holding six-weekly meetings to discuss children at risk and share safeguarding concerns appropriately.

A local care home supported by the service described strong and professional working relationships with the service and reported efficiency, along with regular meetings to discuss improvements in working practices and people’s care.

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, people at risk of developing a long-term condition, and people with caring responsibilities. People who were carers were clearly coded on the clinical system, ensuring they were easily identifiable and could receive appropriate support. The service’s internal frailty team played a key role in identifying carers and signposting them to relevant community services and available options.

A health monitoring machine was available in the service waiting area to facilitate self-screening for people during their visits. The service also maintained information boards with posters and leaflets tailored to the needs of people. These boards were regularly updated to reflect relevant national campaigns, for example, promoting cervical screening during cervical screening awareness week.

Staff actively supported national priorities and initiatives to improve population health, including programmes to reduce smoking and tackle obesity.

The PPG also supported the service through fundraising activities, which helped purchase new check-in screens and a blood pressure monitoring machine for the waiting area that records people’s weight and height.

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 expectations and the expectations of people themselves.

From the clinical notes we reviewed, people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.
The service had effective systems in place to ensure invitations for immunisations, screenings, and reviews were sent appropriately and in a timely manner. The service met most national targets for screening and immunisations. Arrangements to follow up on missed appointments for health checks and immunisations were actioned. Staff also opportunistically offered immunisations or other outstanding tests to people to help improve care outcomes.

The service conducted regular audits to improve individual safety. For example, following a Medicines and Healthcare products Regulatory Agency (MHRA) alert, an audit was carried out to identify people prescribed both an aldosterone antagonist and an ACE inhibitor or ARB who had not had their kidney function or electrolyte levels checked in the past six months, ensuring appropriate monitoring and reducing the risk of adverse effects. Findings of the services audit showed no people were overdue blood tests by more than 2 months, and those identified had already been contacted to book appointments.

The service also carried out regular clinical audits, including 2-cycle audits where data was reviewed and compared 6 months apart. An example of a completed audit focusing on the heart failure register, identified 253 people on the register, 62 potentially missed from the register, and 17 potentially undiagnosed. As a result, 238 records were reviewed to ensure people were on the correct medicine, had appropriately declined treatment, and that referrals were suitable, which applied to 5 people. Additionally, 40 people had a heart failure code added to their clinical records.

The service conducted a comprehensive search of its population to identify people prescribed hormone replacement therapy (HRT). Responses were collated, detailing individual dosages, enabling clinical staff to determine whether a follow-up was required. The service attempted to contact 339 people and received responses from 44. Of those who responded, 31 were appropriately managed on their current HRT regimen, while 10 required dose adjustments. For 4 respondents who had not had an HRT review in over 12 months, these were then arranged. Following this review, the service reinforced prescribing guidance regarding appropriate doses and provided updates to clinicians involved in HRT prescribing to ensure awareness of current guidelines. A plan has been agreed to re-run the audit in 12 months to support ongoing improvement. The service was aware of people who had no responded to seek opportunistic discussions.

The service had created a drug monitoring guide available for staff responsible for monitoring as part of their role. The guide was comprehensive, detailing common medicines where monitoring may be required. It included the drug class, names of drugs, type of monitoring needed, whether blood test monitoring was required, and the recommended frequency.

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.

DNACPR records reviewed as part of this assessment demonstrated, when appropriate, end-of-life and palliative care plans included detailed advanced care plans along with charts for district nursing teams to complete. Out-of-hours services also had access to these records. Evidence showed people were consenting, and when required, families and representatives were present during the consent process. The service also introduced plans, effective from 13 October 2025, for all DNACPR records to be completed electronically. This would allow people’s records to be coded promptly, to ensure out-of-hours teams were aware and enable review dates to be added when required.