Pembroke House 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 assessed all quality statements in the effective key question.

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

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.

Staff demonstrated an understanding of the additional support some people may need when attending their appointment such as requiring a translator or a longer appointment. There were alerts on clinical records about the additional communication needs. People felt involved in the assessment of their needs and felt confident staff understood their individual needs. People presenting with symptoms which could indicate serious illness were followed up in a timely way. The service had a carer support worker who maintained a register of people identified as carers and provided practical and emotional support to them through counselling sessions, quarterly magazines and monthly emails. Health and wellbeing checks were offered to carers to encourage them to look after their own health. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to the social prescriber for support and signposting to relevant services.

Our clinical searches identified 143 people diagnosed with asthma who had been prescribed 2 or more rescue steroids (treatment for severe asthma episodes). We sampled and reviewed 5 records and found 4 of them did not receive follow-up care after acute exacerbations. The service developed an action plan to review the group of people within 4 weeks and update their current processes to be in line with guidance.

The service had systems to ensure staff were up to date with evidence-based guidance and legislation. The service had regular clinical meetings where guidance and cases were discussed.We saw evidence of clinical audits being undertaken to ensure staff were working in line with clinical guidelines. Staff told us they had protected time to complete continuous professional development to keep up to date with changes to care and treatment. The service supported and encouraged staff to pursue further training in their specific areas of interest. However, our clinical searches showed some medicines monitoring and reviews were not in line with national guidelines. The service acted quickly to address these issues.

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 were able to request support from GPs and the leadership team who were visible and approachable. Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The clinical staff frequently discussed people care as a team internally and with external partners such as in palliative care meetings to promote consistent care. Representatives of the care homes that the service worked with provided positive feedback on the arrangement of a community matron (a senior nurse experienced in managing complex, long-term conditions) as their main point of contact which promoted continuity of care for people using their services. GP appointments would be arranged for the people if required after the initial assessment.

The service supported people to live healthier lives and where possible, reduce their future needs for care and support. The service identified people who may need extra support and directed them to relevant services. This included people in the last 12 months of their lives, people 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. For example, social prescribers signposted people to healthy lifestyle activities, such as walking groups and breathing exercises, as well as various community-based services offering financial or housing assistance. The service’s website contained information and links to other sources of information to support people in making healthier choices.

The service did not always monitor people's care and treatment to ensure continuous improvement. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

People with long-term conditions were offered an annual review to check their health and medicines needs were being met. The service had 1,184 people diagnosed with an underactive thyroid, among which 55 of them potentially had not received the required blood monitoring in the past 18 months. We sampled 5 records, and all were overdue with the required blood monitoring. The service developed an action plan to review and manage the group of people within 4 weeks and strengthen the existing recall process. We looked at the potential missed diagnosis of chronic kidney disease (CKD) at stage 3-5 as part of our clinical searches of which 147 people were in this category. We sampled 5 clinical records for review and 1 was a case of missed diagnosis of CKD. The risk of harm was low and the service had followed up with the person. The service explained they had an existing mechanism of clinical searches to identify people with CKD at stage 3. They investigated the case as a significant event and strengthened their current regular search processes by adding another regular search for people at stage 4 or 5 but without CKD diagnosis coding. The identified people would be reviewed and coded as appropriate. However, our clinical searches sampled 5 people at advanced stage of chronic kidney disease to review their clinical care. We identified they received appropriate blood monitoring. We sampled 5 records of people with diabetes who had a HbA1c at 75mmol/mol or above (a high average blood sugar level indicating increased risk of complications) and they had received appropriate reviews.

National data (2023-2024) showed the service had achieved the 90% minimum uptake for 3 out of the 5 indicators for childhood vaccination. The other 2 indicators ranged between 87.4-89.5%. The service was aware of the findings and had taken a series of actions for improvement. For example, clinicians proactively contacted the parents or guardians to address vaccine hesitancy with reassurance and education and promoted the importance of vaccination during children’s appointments for other health concerns. The service also targeted invitations for vulnerable children with incomplete vaccination to promote equity. The service’s unverified data for 2024-2025 showed they achieved the 90% uptake for the 2 indicators that were not reaching target. Latest national data (2024) showed that 66.1% of eligible people aged 25-49 years and 72.1% of eligible people aged 50-64 years had received cervical screening (smear test), which was below the national target of 80%. The service implemented an improvement plan to address this. For example, the service developed tailor-made information for the low-uptake groups to address concerns and cultural stigmas and offered flexible appointments outside core working hours to improve accessibility. The service secured funding for staff training in the cervical screening procedures and to produce an in-house video to be shared on its social media and website to address people’s concerns and anxiety about the procedure of cervical screening. The latest unverified data from the service showed the uptake had improved to 76% (25-49 years) and 83% (50-64 years) respectively.

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. Policies, protocols, and guidance were followed to support people to consent to care and treatment. Clinicians supported people to make decisions.