Marazion 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 in March 2015, we rated this key question as Good. At this assessment, the rating remains unchanged.

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.

The service made sure people’s care and treatment were effective. They appropriately checked and discussed people’s health and care needs with them.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs.

Staff and leaders were aware of the needs of the local community. The service offered people the option of contacting the service by telephone, online or walk in.

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. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber (social prescribing was for people who: have one or more long term conditions; need support with low level mental health issues; are lonely or isolated; have complex social needs which affect their wellbeing). Feedback from people using the social prescribing services was positive.

The service always 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. They worked to develop evidence-based good practice and standards.

Clinical staff had access to relevant national and formulary guidance, as well as local policies/guidelines and used this information to help ensure that people's needs were met.

Staff told us they received regular updates from leaders at the service. Where there were changes in process, staff told us that they were informed and involved in implementing changes.

As part of our assessment, a number of set clinical record searches were undertaken by a CQC GP Specialist Advisor.

We identified during the clinical searches that there were effective reviews and monitoring of patients following receipt of Medicines and Healthcare products Regulatory Agency (MHRA) alerts. For example, those relating to diabetes.

Staff were aware of the need to complete accurate and full records, so that information did not need to be repeated by people when they moved between different services.
People received coordinated and person-centred care. This included, when they were referred to another service, or after they were discharged from hospital. Care and treatment for people in vulnerable circumstances was coordinated with other services. There were established pathways for staff to follow to ensure people’s needs were met.

Multidisciplinary meetings took place that included all GP services within the Primary Care Network (a group of GP services that work together with other local health and social care organisations to provide integrated services for their communities).

Other members of the multidisciplinary team included the Community Matron, Dementia Practitioner, and the Palliative Care Nurse.

There were clear and effective arrangements for booking appointments and transfers to other services.

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 patients’ health, including those 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.

Patients were directed to further information on the NHS website, Patient.co.uk and through support groups. For example, managing diabetes and programmes for maintaining a healthy weight.

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

The service had not met the 2 national targets for cervical screening of 80% from data published in 2023/24. The provider was aware of the population of its service and had undertaken a project to promote cervical screening. The service provided evidence of unverified data, with rates for 2025/26, showing a 3% - 6% increase (from 77% to 80% for the eligible population aged 25 to 49 years old and 79% to 85% for the eligible population aged 50 to 64 years old).

The service had achieved the average national targets for 4 of 5 childhood immunisations from data published in 2023/24. The service was aware of its population. They had identified a significant number of people who did not wish to take up the offer of immunisation or engage in discussions. This impacted the service’s ability to reach the national target year on year. The service took part in immunisation campaigns and actively promoted these. Information about immunisations were provided in various formats and appointments could be arranged with the nurse to discuss immunisations to help inform peoples decision making.

We evidenced during the clinical searches that there were effective reviews and monitoring of people with hypothyroidism (when the thyroid gland does not make enough thyroid hormones to meet the body's needs resulting in symptoms like tiredness and weight gain), and people with Chronic Kidney Disease.

We reviewed the records of people with a missed diagnosis of diabetes. We evidenced 3 out of 5 records reviewed had not been coded on their records and 1 person had not been reviewed in a timely manner after being diagnosed with diabetes.

Following our clinical searches, we obtained evidence at our site visit of the service, which showed that these people’s clinical records had already been reviewed. Records contained information that people had attended appointments for reviews and appropriate clinical care provided.

The provider submitted evidence of 21 clinical and non-clinical audits, which they had carried out to improve outcomes for people. These covered medicines, medicine monitoring, and monitoring access to the service. Leaders and staff told us that audits were discussed at clinical and staff meetings; this was confirmed in the minutes of the meetings we reviewed, which showed the findings were shared and learning outcomes/changes to practice or policies/procedures were cascaded to staff.

People did not raise any concerns regarding the service seeking their consent to care and treatment.

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

Relevant staff had been provided with training in the Mental Capacity Act. The service monitored the process for seeking consent appropriately and patient record searches demonstrated that consent was recorded appropriately, this included when minor surgical procedures was carried out.

Staff we spoke with demonstrated the importance of ensuring that people understood the care and treatment offered before obtaining consent. For example, consent forms were sent to the people using a digital platform, which provided people with all the information about the procedure, including risks. This allowed for a cool down period before people agreed to the procedure following their consultation.

We reviewed Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions for 3 people and found they were not always maintained in line with relevant legislation. The service had an ongoing DNCPR audit in progress, which had identified issues and actions were being appropriately taken to address this. For example, training and clinical supervision/governance.