The Park 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 83 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

he service always 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 felt involved in any assessment of their 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. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. Our clinical searches showed the provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The practice had developed a new staff role of frailty and vulnerable persons care coordinator to enhance engagement with patients with a learning disability and patients over 75 years. The practice had identified patients over 75 years health check as a priority area for improvement and had developed this role to assist in proactively contacting this target group to offer a health check. They had 2096 patients aged over 75 and of these 1760 patients had had an appointment for a long-term condition review, medication review or new health problem in the past year. 331 out of total of 353 eligible patients had had a polypharmacy medication review in the past year.

The practice ensured patients with a learning disability received annual health checks and had invited 67 of their 70 patients with a learning disability for a health assessment and had completed 56 of these health assessments in the last 12 months. The frailty and vulnerable persons care coordinator would also be working with this group of patients to improve uptake of these reviews.

The practice was working towards risk stratifying patients so that those at greatest risk were prioritised. They had worked with the Primary Care Transformation lead public health team to develop a tool to improve this area. As part of their risk stratification, they had identified diabetic patients with the highest risk of cardiovascular disease for priority assessment by the pharmacy team. This was to improve the numbers of patients accessing medicines to reduce their risk of heart failure, hospitalisation and cardiovascular death.

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.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance. The practice had an audit programme to monitor the standard of care being delivered. Outcomes of audits were shared in clinical meetings and actions for improvement were recorded and implemented. For example, one audit reviewed if patients had been followed up following an exacerbation of their asthma as per National Institute for Health and Care Excellence (NICE) guidance, they found 4 of 9 patients had been. To improve this area, they had created a dedicated follow up slot in the appointments calendar and patients were to be booked into this slot following an exacerbation of their asthma. A second audit showed all patients had been followed up as per the guidance and this was confirmed in our clinical searches.

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 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. The practice was involved with the cancer alliance project, and the GP assistant was the named practice representative for the PCN. The project was reviewing the quality of cancer care reviews as patients had reported they were not finding them particular useful. The member of staff involved told us they will be shadowing the Macmillan teams to better understand the support systems to aid this work.

The service always supported people to manage their health and wellbeing to fully 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 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 practice had worked closely with community services such as the local food bank to provide information and advice relating to health improvement strategies. The practice had a health room at the main site with a monitor which patients could use to check their own vital signs such as blood pressure, height and weight. A wide range of patient information leaflets was also available in this area. The practice had a dedicated member of staff who worked with patients with a learning disability and information relating to health screening was provided in easy read formats.

The service monitored all people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

The practice met national targets for screening and immunisations. The national target for cervical screening coverage is 80%. The most recent data (2023) showed the practice had achieved 81.15% and had achieved the 80% target for at least 9 years prior to this. The national target for routine childhood vaccinations is 90% coverage. The World Health Organisation (WHO) recommends a rate of 95% for all routine childhood vaccinations. Those practices achieving this level are considered an example of good practice. The most recent data (2023/24) showed the practice had exceeded 95% in 4 of 5 routine childhood vaccination age groups and had maintained this achievement for last 10 years and in the other area had exceeded 90% and had maintained this or exceeded the 95% target for last 10 years.

From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. Audits completed by the practice in the last 12 months included a review of patients under 11 years of age who attended the practice, out of hours services or A and E frequently. Identified areas for improvement were discussed in a clinical meeting and actions for follow up were recorded. Actions implemented included the practice working closely with the integrated neighbourhood teams and a ‘when should I worry’ information text and social media campaign was developed and implemented. Training for clinicians in the management of eczema was also provided. A second audit did not show any significant decrease in attendance, but the practice was continuing to review additional strategies with local services to manage this area.

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. The practice had developed policies to ensure patients consent to care and treatment decisions took account of any communication or information needs relating to a disability, impairment or sensory loss. Patient record system templates were used to record consent to ensure consistency and to show patients' needs had been considered. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. Staff we spoke with were knowledgeable in this area and had received relevant training.