Rectory Meadow 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 inspection, we rated this key question as Good. At this inspection, the rating remains the same and continues to be rated Good.

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.

The practice always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from people using the practice was positive. People felt involved in the assessment of their needs and felt confident that staff understood their individual and cultural needs. Staff were long standing, patients had named GPs (for routine care) and staff were aware of the needs of individuals, families and 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 an interpreter to be present.

Staff checked people’s health, care, and wellbeing needs at initial registration and during health reviews. For example, following a recent significant event, concerning a patient with respiratory concerns, the practice amended the asthma pathway to anticipate and manage risks whilst optimising asthma management. This included how individual patients’ needs were assessed and managed from the moment they received an asthma diagnosis or when an asthmatic patient joined the practice. Clinicians advised the initial proactive assessment of asthma included reviews of inhaler usage; inhaler technique and the importance of asthma management had already improved safety and asthma related outcomes. This proactive approach to anticipating and managing risks to people who use services was being embedded to other long-term conditions and was recognised as the responsibility of all staff.

Clinical staff used templates when conducting care reviews to support the review of peoples’ wider health and wellbeing. 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.

To ensure patients had their needs assessed and had effective and optimised health outcomes, the practice was working to introduce a system based on population segmentation data, to assess needs and prioritise those at greatest risk of deterioration prior to winter. Patients had been scored and categorised based on their clinical complexity and level of healthcare needs. At the time of the inspection, the practice had concentrated on Patient Need Group 10 “multi-morbidity, multi-complexity” and Group 11 “frailty”, drawing further information from GPs, social care and social determinants of health. There were 80 patients in Groups 10 and 11 and these groups are updated on a monthly basis.

There was a register of 28 patients aged over 14 with a learning disability. Records showed that all 28 patients (100%) had been offered an annual health check and at the time of our inspection, 18 of the 28 patients (64%) had a completed health check (between January 2025 and October 2025). In addition, staff told us the difficulties, challenges and health inequalities people with learning disabilities faced when taking part in cancer screenings. As a result, staff shared techniques and information, including easy read and video information from the local PCN which they used to promote, invite and support cancer screening for this cohort of patients.

The practice 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. There was targeted and focused clinical audit activity undertaken throughout the year to ensure care was evidence based, staff told us this was linked to the practice’s quality improvement programme.

Systems were in place to ensure staff were up to date with evidence-based guidance. For example, staff involved in diabetes management had recently completed additional diabetes training designed to upskill diabetes staff working in primary care. There was a strong emphasis on learning within the practice and regular meetings were held to support the sharing of information. The practice held monthly educational sessions where topics were chosen dependent upon recent changes and updates in guidelines and clinical cases. To share learning, staff not employed by the practice were invited to join these sessions, for example PCN staff who were located within a different area of the building were invited to learn. Clinical supervision was in place.

The remote clinical searches we undertook of the practice’s clinical records system showed the monitoring of people with long-term conditions was in line with National Institute for Health and Care Excellence (NICE) recommendations and staff delivered evidence-based care.

The practice 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. This included activity and engagement with the newly emerging Integrated Neighbourhood Teams. Integrated Neighbourhood Teams are collaborative groups within the NHS that bring together various health and social care services to improve population health and wellbeing.

Staff feedback was positive about how the teams and individuals worked together within the practice. We saw evidence of regular GP, nurse, admin, reception, and all staff meetings which included a fixed agenda item for suggested improvements.

Staff told us the practice worked well across teams and services to support people. They highlighted leaders had made positive changes and implemented new channels of communication to improve how staff worked and delivered together. This included when patients moved between different services including referrals to secondary care.

The practice supported patients to manage their health and wellbeing to maximise their independence, choice and control. This included supporting patients to live healthier lives and where possible, reduce their future needs for care and support. Staff provided examples of referrals to the health and wellbeing coaches employed through the PCN and also to a local Buckinghamshire scheme, known as Be Healthy Bucks. Be Healthy Bucks is a free health and wellbeing service to help people make simple changes whilst focusing on creating long-lasting behaviour changes to adults and children which includes national and local health priorities such as smoking cessation, weight management and reducing alcohol consumption.

Practice staff had access to live and integrated resources to refer and signpost patients to non-clinical interventions, including social prescribing resources. Staff highlighted this had further improved coordination of care when referring patients to local health resources.

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. At the time of our inspection, the practice shared new population health data which highlighted significant variation in cancer diagnosis within the locality. Staff had already reviewed and discussed audit activity to identify if any improvements could be made within primary care and the local community to support healthier lives and improve cancer outcomes.

The practice led and delivered Saturday morning group consultations. Recent sessions had focused on falls prevention, managing pain, improving sleep, pelvic health and post-natal care. Patients and the practice had worked together to plan and schedule further health promotion and Saturday morning group consultations throughout 2026.

The practice website and designated areas within the practice contained detailed information and links for health promotion, specific conditions and common questions. For example, there was a children’s area within the practice which included children specific health promotion, such as childhood immunisation information.

Additionally, a practice GP had given talks at the local grammar school on subjects including sexual health and mental health, the practice told us, this had been well received.

The practice monitored patients 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.

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.

The practice exceeded the World Health Organisation (WHO) national target of 95% (the recommended standard for achieving herd immunity) for 4 of the 5 childhood immunisations. To increase and sustain uptake, the nursing team had commenced clinical audit activity with a view to review and further increase uptake to address the surge in childhood infections (measles) and protect the wider community. Early data indicated the audit activity showed a positive impact, and unverified data showed the remaining immunisation indicator was over 95% at the time of our inspection.

Data from June 2024 showed the practice had a combined cervical cancer screening uptake rate of 76.3%, which was below the expected 80% target. Nursing staff told us they had worked together, utilised the nurse secretary (a role designed to support and complete all nurse administration) to review uptake, communicate with patients and reduce the barriers to uptake. For example, the practice offered longer appointments for patients who had questions or concerns about cervical screening. Whilst unverified, live data collected at the inspection indicated improvements had been made and in November 2025 the combined uptake rate had increased to 79%. We saw evidence of scheduled screening appointments booked where staff aimed to see an increase in cervical screening uptake rates.

The practice had a system in place for completing a wide range of completed clinical audit cycles. These included audits for prescribing, mental health, cancer screening and audits of a variety of long-term conditions.

They followed up audits with recommendations based on the findings of the audits and action plans to support the recommendations. We saw evidence of second cycle audits taking place to evidence that improvements had been made.

The practice told patients about their rights around consent and respected these when delivering person-centred care and treatment.

Chaperones were available upon request. This information was on display in the form of posters throughout the practice.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. We looked at a sample of ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions in patient records to ensure that DNACPR decisions were made in consultation with the patient or, where appropriate, their family/carers. Appropriately completed documents were available, made in line with relevant legislation and had been shared with other relevant services and alerts had been added to the patient record system. Relevant documentation demonstrated in the care records of patients assessed as not having capacity to make certain decisions.