Claremont Bank 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 67 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff checked people’s health, care, and wellbeing needs during health reviews. 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 19 patients on the learning disability register. For the current period April 2025 – April 2026, 4 patients had received an annual health review. All of the remaining patients had been scheduled for health checks throughout the year to ensure timely and comprehensive care. Reasonable adjustments had been implemented to improve access for these patients, including adjusting appointment formats or times to meet individual communication or sensory needs.

Feedback from people using the service was mainly positive in relation to the assessment of their needs. Most people felt involved in the assessment of their needs and felt staff understood their individual needs.

The practice planned and delivered people’s care and treatment with them, including what was important and mattered to them.

The practice had systems in place and a designated clinical lead to ensure staff were up to date with evidence-based guidance and legislation. These included: a practice nurse facilitator support, monthly clinical meetings, in house training, a GP lunchtime forum where a wide range of clinical topics were presented and discussed, appraisals and personal development, information governance and quality alerts.

The remote clinical searches we undertook included reviewing the monitoring of people with long-term conditions to assess if National Institute for Health and Care Excellence (NICE) recommendations were followed.

Our remote clinical search identified the practice had 611 patients with asthma. We reviewed the clinical records for 5 patients with asthma who had been prescribed 2 or more courses of rescue steroids in the last 12 months. We found patients had received the appropriate treatments and monitoring, however, 2 of the 5 patients had not been followed up after acute exacerbations in line with NICE recommendations.

Our remote clinical search identified the practice had 339 patients with hypothyroidism. We sampled 4 of these patient records and found they had not received a thyroid function test monitoring for 18 months. However, we saw all 4 patients had been invited to attend for a blood test. We saw 2 of the 4 patients had not received blood monitoring for 3 years. Following our clinical searches the practice took action and shared their findings and the action with us. They confirmed 2 of the patients had since attended for their thyroid blood test, 1 patient had since had their medication quantity reduced but had still failed to attend for blood monitoring, despite being advised about the importance of this and being sent further text reminders. A further patient had also failed to attend for blood monitoring despite several requests made. As a result they had been advised their supply of medication would be reduced if they failed to attend. Since our search was carried out the practice advised a new patient had since registered with the practice and had been requested to attend an appointment for blood testing.

Our remote clinical search identified the practice had 465 patients with diabetes. We sampled the records of 5 patients with diabetes who’s latest HbA1c (blood glucose) level was consistently high. We found these patients were generally well monitored and reviewed.

Our clinical searches identified 26 patients with chronic kidney disease stages 4 or 5. We found 3 of these patients had potentially not had the required blood monitoring to assess their kidney function in the previous 9 months. Of these 1 patient had received a renal transplant and 1 of the 2 patients had received a recent urine albumin to creatine ratio (ACR). The practice told us they would take action to ensure the other patient received an ACR.

The practice worked well across teams and services to support patients. 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 and held regular multi-disciplinary team meetings to discuss and share information, for example vulnerable patients and patients nearing end of life. The practice was an active member of the Shrewsbury Primary Care Network (PCN) and worked together to provide a wide range of services.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. The practice supported people to live healthier lives and where possible and reduce their future needs for care and support. Patients had access to a social prescriber and care co-ordinator via the PCN to support them with lifestyle changes. They were able to offer support with a range of aspects including emotional wellbeing, healthy lifestyle choices and were signposted to other agencies and local support groups.

Staff supported national priorities and initiatives to improve population health and were able to refer patients to a smoking cessation service run by the local authority or to the NHS diabetes prevention programme where appropriate. NHS health checks, for patients aged 40 – 74 without pre-existing conditions, were offered via their Primary Care Network (PCN) to help identify any risks, discuss lifestyle and provide advice. Leaders told us they were supporting the PCN with a breast screening campaign. Patients also had access to a cancer care co-ordinator via the PCN who offered support and signposting.

During our site visit we saw a range of health promotion information material was available within the waiting room and was also available on the practice website.

Since our last inspection the practice had become an Armed Forces veteran friendly accredited GP practice, ensuring veterans received the most appropriate care and treatment and were identified for priority access.

The practice monitored patient’s care and treatment to continuously improve it. Staff ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of patients. 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.

A review of the most recently published data showed the practice cervical screening uptake for their eligible population aged 25 to 49 years old within the last 3.5 years was 75%. The uptake for their eligible population aged 50 to 64 years old within the last 5.5 years was 82%. The national target is 80% for both indicators.Patients were able to access early morning appointments for cervical screening with the lead nurse, who had adjusted her working hours to start earlier at 7:30am to improve access to appointments.

The practice had exceeded the 95% target in 4 of the 5 childhood immunisation indicators and achieved 87.3% for the percentage of children aged 5 who had received immunisation for measles, mumps and rubella (two doses of MMR). This was just below the minimum 90% target. The World Health Organisation (WHO) recommends a rate of 95% for all routine childhood vaccinations. The practice advised of the challenges they had experienced with the uptake of MMR and had arrangements in place to follow up immunisation appointments when a child was not brought, or the appointment cancelled and not rebooked.

At the last inspection we found the practice had a limited programme of quality improvement. At this assessment this had improved. The practice had developed a quality improvement plan and a range of clinical and non-clinical audits were undertaken, including a limited number of 2 cycle audits to reassess practice and measure improvements.

Staff were able to share examples in relation to assessing capacity and obtaining consent. However, the practice did not consistently tell people about their rights around consent and did not always respect their rights when delivering care and treatment. The practice clinical system identified 36 live patients as having a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form in place. These forms are generally used for people with complex health needs and completed with the individual, family if desired and healthcare professionals about their care in the event of an emergency, retained by the person and scanned onto their clinical records. During our site visit we sampled 6 of the 36 patient records and found all but 1 patient had a ReSPECT form on their records. We saw 2 patients were considered as not having capacity to consent. However, there was no record of a completed mental capacity assessment being undertaken. Following our site visit, the practice told us they would be developing a ReSPECT form protocol to ensure that the forms were processed thoroughly, including documentation of a mental capacity assessment at the time of completing the form.

Where appropriate, patients were offered a chaperone for care and treatment. During our site visit we saw chaperone posters were displayed to inform patients of this service. Staff providing this service were provided with training.