Archived: Lichfield Grove 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

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved relevant people who took decisions in people’s best interests where they did not have capacity.

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. People felt involved in any assessment of their needs and felt confident staff understood their individual and cultural needs.

Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff checked people’s health, care, and wellbeing needs during health reviews. Doctors and clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing.

The service had systems to identify people with previously undiagnosed conditions. However, our clinical searches identified a small number of people with a potential missed diagnosis of chronic kidney disease and of diabetes. We spoke with the service about the potential missed diagnosis of patients and provided them with patient numbers for them to undertaken their own searches. The service (subsequently) told us of the action they had taken to We conducted remote clinical records searches to assure ourselves that the care provided by the service was in keeping with national guidelines.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this mostly in line with legislation and current evidence-based good practice and standards.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. However, not all clinical records we saw demonstrated care was provided in line with current national guidance. We noted that a small number of records we looked at relating to patient medicines reviews, had not been completed comprehensively. On the patient records we viewed, there was limited updated information on the records as part of the medicines review, indicating that an in-depth review of prior patient notes had not been undertaken as part of the review. There was no evidence that the service used a template to undertake the review and therefore there no detailed assessment of patient compliance with medicines or any reported side effects with medicines prescribed was contained as part of the updated information.

The service worked well across teams and services to support people. 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.

Staff were positive about how the service worked well and with external services to support people. There was evidence of working with wider health care teams, however regular multi-disciplinary teams (MDT) meetings did not occur. The service told us practice staff contacted individual services (where care of patients was shared) when an exchange of information relating to a specific patient was required. People had access to services provided via the Primary Care Network (PCN), including, social prescribers and health and wellbeing coaches.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured outcomes were positive and consistent, and they met both clinical expectations and the expectations of people themselves. Staff focused 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 did not meet all the national targets for screening and immunisations. The service had achieved all but one out of the 5 indicators from the World Health Organisation (WHO) for childhood immunisations, however uptake of cervical screening was 60% which was below the national target of 70% according to published data at the time of this assessment. As part of the assessment, the service provided the assessment team with local data relating to the number of cervical screening appointment uptake. This data which showed a varied uptake between the months of August 2024 and January 2025, with the highest number of screening appointments in a month being 33 and the lowest being 12. The data provided by the service was gathered using different methodology from the data sources available to the assessment team, and therefore the data provided by the service was not directly comparable. There is a recall process in place to remind patients when they are due for immunisations or screening. The service told us that as part of the PCN network after-work and weekend clinics were available to patients who were unable to have screening done during a working day.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. People’s feedback demonstrated they felt at ease during consultations, were listened to and procedures were explained well. People were appropriately informed when making care and treatment decisions.

The service told us they supported people to make decisions, and where appropriate, they assessed and recorded a person’s mental capacity to decide. Clinicians told us they always obtained consent from people (or their carers if applicable) and offered a chaperone where appropriate, which was recorded on the clinical system. Staff told us they had completed training on consent and the Mental Capacity Act. Staff we spoke with had a good understanding of consent.

People were offered a chaperone, and posters were displayed in the practice informing people this was available to them. Staff who carried out chaperone duties were trained for the role and had received a disclosure and barring (DBS) check. The practice had systems and processes in place to obtain consent to care and treatment in line with legislation and guidance.