Swan 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 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.

The service planned and delivered people’s care and treatment with them, including what was important to them. They mostly did this in line with legislation and current evidence-based good practice and standards. The provider had systems in place to ensure staff kept up to date with evidence-based guidance and legislation.

The service proactively invited people to contact the care coordinator team so tests needed for people’s long term condition reviews were coordinated and completed before their review. This was also used as an opportunity to revisit and encourage attendance, for example for health checks. A range of clinical staff supported the review process to ensure the effective use of skills and expertise. People with multiple long-term conditions were reviewed during 1 longer appointment to reduce the need for multiple visits and full medication reviews were also undertaken where possible. People and care home representatives gave positive feedback in relation to the clinical care and treatment received.

As part of our assessment, we conducted a detailed review of people’s care records. The records demonstrated that people with a potential diagnosis of diabetes had received the appropriate care and treatment in line with guidance. For example, the service reviewed the management of people with newly diagnosed type 2 diabetes in the previous 12 months and identified a 19.3% reduction in HbA1c. (A blood test which measures average blood glucose levels over the previous few months). The records also demonstrated people with hypothyroidism had received the appropriate monitoring.

People with diabetes who had elevated HbA1c levels were not always managed appropriately, which included some people whose care was shared with local diabetes services. The provider recognised the need to strengthen joint working with partners and enhance monitoring arrangements to ensure oversight of people with diabetes, including those for whom another service held primary clinical responsibility. The provider took immediate action to review all affected people, clarify clinical responsibility, assess risk, and implement any required follow-up actions. Arrangements were in place to oversee and monitor this work, and policies were updated and shared with staff.

The records demonstrated that best practice for the follow up of people experiencing an exacerbation of asthma had not been followed, although we noted clinicians had attempted to review people recently. The provider acknowledged they needed more robust monitoring of people who had recently received treatments for an exacerbation of thier asthma.In response, they took immediate action and reviewed all people identified in the search. Where people had not engaged, they remained on the waiting list for active follow up. Post review audits had been completed and every person had either had a review, were scheduled for a review or did not require a further asthma review. The strengthened their processes to ensure people who experienced an exacerbation of asthma were identified and booked for a review appointment by the care coordinator team. Policies were updated and shared with staff.

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 focussed on identifying risks to people’s health, including those in the last 12 months of their lives and those with caring responsibilities. Service leaders and staff supported national priorities and initiatives which included for example, stopping smoking and weight management. The social prescriber also signposted people to weight loss programmes which included offering gym passes and weight loss class vouchers. Information was available in the waiting room areas and on the service’s website which signposted people to self-referral information and local and national support groups to encourage healthier living. Staff we spoke with told us messages about national health promotion campaigns were regularly shared on the service’s social media platforms. These included world heart day, healthy ageing month and support for people experiencing suicidal thoughts. The service also worked in partnership with the Patient Participation Group and had held events for example, to raise awareness of pre-diabetes and menopause.

The service had effective arrangements in place to provide a range of health checks, including NHS Health Checks for eligible people, physical health checks for people with a severe mental illness, and annual health checks for people with a learning disability. From April 2025 to March 2026, 94% of people with a learning disability received an annual health check. Arrangements were in place to follow up with people who had not responded to invitations and to recall people who had previously declined to attend, to support ongoing engagement.

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. For example, the service had introduced a treatment for eligible people with established cardiovascular disease. Results showed 53 people had successfully commenced treatment with an average reduction of 55% of low-density lipoprotein (LDL) cholesterol. LDL cholesterol carries fatty deposits into artery walls and can lead to blocked blood flow and heart problems.

The service met the target for 3 childhood immunisations indicators, was slightly below the national target for 1 indicator and exceeded the national target, meeting the World Health Organisation target for another indicator. The service performed above the national targets for breast and bowel cancer screening. Cervical screening uptake was below the national target for women aged 25 to 49 years and slightly below the national target for women aged 50 to 64 years. Leaders were aware and had acted to increase nurse capacity. Staff told us the uptake of cervical screening had increased, and the service provided unverified data which supported this view. Effective recall systems were in place and flexible appointment times, evening appointments at a nearby service and on some Saturdays for prearranged appointments.

The service had developed arrangements to support the top 1% of people with the highest intensity use of services. Multi-agency teams were in place and were awaiting the allocation of identified individuals to begin coordinated support through an intensive multidisciplinary approach.

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.