The Heron Practice

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 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 assessed and reviewed patients' health, wellbeing and communication needs to support effective care and treatment.

Systems were in place to identify and record access and communication needs through coded alerts and electronic records. NHS Health Checks and targeted searches supported identification of patients at risk of developing long-term conditions. Specific attention was given to vulnerable groups, including asylum seekers and carers. Carers were supported through a dedicated register, proactive reviews and community support initiatives.

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

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation.

Clinical audits, prescribing reviews, QOF monitoring and recall systems supported adherence to national guidance. Clinical staff participated in regular training, professional forums and quality improvement activities that supported evidence-based practice.

The service worked effectively across teams and services to provide coordinated care and support continuity for patients.Information was shared through multidisciplinary meetings, clinical discussions, electronic records and communication systems. Regular MDT meetings supported collaborative care planning for patients with complex needs. Community nurses, pharmacists and other professionals worked closely with the practice and shared information to support safe care transitions. Systems enabled staff to access the information required to assess, plan and deliver care effectively.

The service supported patients to manage their health and wellbeing and promoted healthier lifestyles.

Staff proactively identified opportunities to support smoking cessation, weight management and preventive healthcare. Automated recall systems supported long-term condition reviews and health checks. The service offered social prescribing alongside wellbeing initiatives including walking groups, gardening activities and community support projects.

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.

The service had systems to monitor care and treatment and described processes to improve uptake of cervical screening and childhood immunisations. Staff used recall systems, opportunistic screening and electronic alerts to identify patients requiring screening or vaccination, and non‑responders were followed up.

Published cervical screening data available at the time of assessment showed uptake below the national target for the relevant cohorts. Published childhood immunisation data for the same period also showed uptake below the World Health Organization target across several vaccination programmes.

The provider supplied more recent local dashboard data for both cervical screening and childhood immunisations. As this information had not been independently validated through national reporting systems, it could not reliably demonstrate the extent of improvement.

Staff nevertheless described ongoing work to improve uptake, including reviewing non‑responders, using clinical searches to identify outstanding vaccinations and screening, and adapting their approach based on emerging risks and population needs. These activities indicated an effort to improve outcomes, although published data continued to show performance below national targets. Clinical audits, prescribing reviews, QOF monitoring and recall systems supported adherence to national guidance. The introduction of automated recall systems improved the management of long-term conditions and reduced missed reviews.

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. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.