Oldfield 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 Requires Improvement. At this assessment, the rating has changed to Good.

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 was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff carried out regular health reviews to check people’s physical, mental and social needs. Clinicians used structured templates during care reviews to ensure wider health and wellbeing were considered. The service had systems to identify people with previously undiagnosed conditions, supporting early intervention and safer care. Staff added digital flags to care records to highlight people’s requirements, such as longer appointment times or the need for a translator. Feedback from people who used the service confirmed they felt involved in their care planning and understood the next steps of their treatment.

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.

The service had systems 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 and best practice. Staff used national guidelines when diagnosing and treating conditions, and they regularly checked treatments were right for each person. A recent quality improvement project, reviewing the management of ear infections, showed some people were given antibiotics they did not need. After this, the service changed how they worked: they now record key symptoms more carefully and use ear drops instead of tablets when this is the safer option and in line with best practice. These changes meant people got the right treatment first time and avoided the unnecessary use of antibiotics. Staff told us they share learning from audits in team meetings, so everyone follows the same approach.

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.

The service was supported by care co-ordinators within their local primary care network (PCN), who were effective in bringing together multidisciplinary teams to support people with complex health and care needs, such as arranging appropriate support and connecting people with services through referrals.

The service worked closely with other teams to maintain continuity of care, especially when tasks were delegated or specialist input was required. For example, during diabetes reviews for frail older people, medicine changes were agreed in multidisciplinary meetings and followed up by the diabetes specialist nurse to make sure adjustments were made and monitored. Staff were proactive in arranging multidisciplinary team (MDT) meetings for complex cases. These included monthly meetings with care homes involving GPs, nurses, dietitians, mental health teams and the palliative care team. Actions from these meetings were recorded in people’s care records using standard templates, ensuring clarity and accountability. When staff identified someone needed support beyond what the service could provide, they adapted their approach and escalated to the right team. For instance, GPs attended best interest meetings with social workers, advocates and legal representatives to make decisions for people who lacked capacity. The service also worked with commissioners and community teams to prevent unnecessary hospital admissions.

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.

The service offered NHS health checks, cervical screening and vaccination clinics, including outreach for housebound people or people attending the Julian House, which supports people experiencing or at risk of homelessness. The service provided lifestyle support through smoking cessation and weight management referrals and ran clinics for diabetes and long-term conditions. Staff worked with other services to make sure people had access to specialist advice when needed.

Staff considered the needs of carers and those with caring responsibilities. They offered flexible appointments and signposted carers to wellbeing services and social prescribing support. Carers were included in care planning discussions where appropriate, and staff ensured they had access to information about health checks and vaccinations.

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

The service had effective systems for monitoring clinical outcomes and improving care. Quality improvement projects focused on antimicrobial stewardship and cholesterol management, which reduced inappropriate prescribing and improved lipid control. Significant events were reviewed promptly, with actions documented and shared in meetings to prevent recurrence.

Staff confirmed involvement in audits and learning sessions, and records showed changes implemented after reviews, such as medication safety alerts and recall improvements.

The service monitored people with long-term conditions and recalled them by their birthday month for review. Each person had a personalised care plan and was supported to discuss their care and treatment at their annual review. The service had effective systems to ensure invites for immunisations, screenings and reviews were sent appropriately and in a timely manner. They also had arrangements to follow up on missed appointments for health checks and immunisations. Staff opportunistically offered immunisations, or other outstanding tests, to people to help improve care outcomes.

People told us they felt confident in the care they received, and the results from the 2025 National GP Patient Survey showed 92% of respondents had confidence and trust in their healthcare professional.

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

Staff understood and applied the principles of consent and the Mental Capacity Act. Mental capacity assessments and best interest decisions were completed and documented using standard templates. Consent processes were embedded in routine care, including cervical screening and vaccination programmes, to ensure people were fully informed before treatment. Capacity and consent were clearly recorded in care notes.

Decisions not to attempt cardiopulmonary resuscitation (DNACPR) were made appropriately and followed relevant legal requirements. These decisions were documented in people’s records and reviewed regularly to reflect any changes in circumstances. Staff confirmed they had received training on consent and safeguarding and demonstrated confidence in applying this knowledge in practice.