King Edward Road Surgery

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• 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 appropriate advice and support. People were involved in assessments of their needs, and staff reviewed these regularly, taking account of their communication, personal and health needs. Care and treatment were delivered in line with current evidence and good practice. Staff worked collaboratively with partner agencies involved in people's care to achieve positive outcomes and support smooth transitions between services. People were given the information they needed to understand their care and treatment and make informed decisions. Where people lacked capacity, staff involved those important to them and acted in accordance with relevant legislation and guidance to support decisions made in their best interests. There were effective systems to monitor and support patients with long-term conditions. This key question has been rated as 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 practice made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. Feedback from people using the service was predominantly positive. Results of the National GP Patient Survey (published in July 2026) showed 91% of patients felt their needs were met during their last GP appointment compared to the national average of 90%. 92% of patients felt the healthcare professional they saw had all the information they needed about them during their last appointment compared to the national average of 92%. 76% of patients surveyed said the healthcare professional they saw or spoke to was good at considering their mental wellbeing during their last appointment, compared to a local average of 73%. Leaders and staff told us the practice used codes and alerts on the patient’s record to highlight special needs and requirements. 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 practice 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 planned and delivered people’s care and treatment with them, including what was important and mattered to them. Meetings were held to ensure staff were updated with the latest information, guidance and changes within the practice.

The 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. For example, one of our clinical record searches reviewed the number of patients with asthma who had been prescribed 2 or more courses of rescue steroids in the last 12 months. We identified a total of 51 patients and reviewed a random sample of 5 patient records. We found that all patients in the sample had been managed appropriately. However, we found gaps in records of formal follow up reviews for some patients. Leaders we spoke with advised they had already undertaken an audit of this area 2 months prior to our assessment and developed a protocol for ensuring documented formal follow up of all patients in the future which they planned to monitor through repeat audits. During our assessment, leaders provided documented evidence to support this.

We reviewed patients with chronic kidney disease (CKD) stages 4 or 5 to check the appropriate monitoring had been undertaken. Our search identified 1 patient, and we reviewed their records. Our clinical review found they were receiving appropriate monitoring.

We reviewed monitoring of people with hypothyroidism (when the thyroid gland does not produce enough thyroid hormone that can lead to tiredness and weight gain). Our search identified 385 patients diagnosed with hypothyroidism, and we reviewed records for 5 of these. We found they had all received appropriate monitoring in the preceding 18 months.

We reviewed the monitoring of diabetes care and found that 92 patients appeared to have not been reviewed, despite having HbA1C levels of 75mmol or more. (HbA1C is a blood test that measures the average blood glucose levels over a period of 2 to 3 months). We reviewed a random sample of 5 patients and found no concerns with the management of their care.

The practice held registers for patients and provided annual health checks for those with learning disabilities, people with severe mental health conditions and palliative patients. The practice shared evidence of clinical audits undertaken to effectively improve patient care.

The practice 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.

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. The processes in place enabled staff to liaise regularly with community teams such as district nurses, health visitors, and palliative care nurses. Staff told us and we saw evidence of regular multi-disciplinary team meetings that were held with external agencies where vulnerable people were discussed and actions were recorded. The practice regularly discussed patients receiving end-of-life care.

The practice supported patients living in 5 local residential care homes and 2 neurological rehabilitation centres. There was a dedicated GP lead for each service and a dedicated administrator who acted as a key point of contact for the services to ensure they received timely support. Feedback received from leaders at 4 of these services was extremely positive. They described consistently good care, efficient communication and improved coordination of care for care home residents. They reflected positively on the benefits of regular ward rounds, continuity of care and said that their concerns were always listened to.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff were consistent in supporting people to live healthier lives through a targeted and proactive approach to health promotion and prevention of ill health, and every contact with people was used to do so. Staff focused on identifying risks to people’s health, including those who are (or might be) vulnerable such as those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The provider worked with its primary care network (PCN) to provide group patient education sessions at the location in Christchurch Medical Centre. They ran sessions to support menopause and diabetes amongst others.

The practice 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.

At the time of our assessment, the latest published information from the UK Health Security Agency (UKHSA) for the period April 2025 to March 2026, showed that the practice had exceeded the World Health Organisation minimum target of 90% for the number of children immunised against various infectious childhood diseases for 4 out of 5 immunisation targets. The percentage of children aged 2 who had received their immunisation for Haemophilus influenza type b (Hib) and Meningitis C (MenC) (i.e. received Hib/MenC booster) was 89%.

The latest published information available to the CQC from NHS Digital (June 2024) showed the practice’s uptake for cervical cancer screening for women aged 25 to 49 years old was below the 80% national target, observed at 65.8%. The practice’s uptake for cervical cancer screening for women aged 50 to 64 years old was also below the 80% national target, observed as 74.2%. Leaders advised they had undertaken targeted work to improve cervical cancer screening uptake. This included providing patient information in different languages which had been impactful. They were able to share unverified data for the periods ending March 2025 and March 2026. This showed the practice’s uptake for cervical cancer screening for women aged 25 to 49 years old was 90.4% in March 2025 and 91.2% in March 2026. The practice’s uptake for cervical cancer screening for women aged 50 to 64 years old was 93% in March 2025 and 89.2% in March 2026.

The practice told people about their rights around consent and respected these when delivering person-centred care and treatment. People we spoke with and the evidence we reviewed did not raise any concerns around consent. People understood their rights about consent to the care and treatment they were offered. Clinicians understood the requirements of legislation and guidance when considering consent. Clinicians supported people to make decisions ensuring their views and wishes were considered during care planning. Assessments of mental capacity were carried out when needed and were decision specific. Staff told us they were able to adapt or translate information about care and treatment so that people could understand it, to support them making informed decisions. All staff we spoke with had completed relevant training and were able to discuss how to gain informed consent for treatment. We reviewed a random sample of staff training records which showed all staff had up-to-date training on informed consent and the 2005 Mental Capacity Act (MCA). We saw that consent was documented and processes were in place for chaperones to be present if requested.

In line with locality requirements, the practice had transitioned from the use of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions to Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms. We reviewed records for 5 of these patients and found that for 4 out 5 patients these were appropriate, regularly reviewed, and made in line with current legislation and professional standards. For the remaining patient the decision record was not readily available, although it was eventually sourced. Leaders took a proactive approach to feedback and undertook a full audit of all patients with DNACPR/ ReSPECT forms to confirm all decisions were recorded and readily available. Review of the audit found there were no gaps in record keeping.

Leaders discussed work they had undertaken with local care homes, upskilling senior care staff to support timely completion of DNACPRs by the clinical team. This included training in discussions with family and sharing information in advance to support effective discussions. They also ensured that a physical copy of the record was available in patient records held at care homes. This was due to care homes not having access to the Northamptonshire Shared Care Record portal.

Leaders advised the practice was a pilot site, working with local nursing homes to provide care home staff with online access to the Northamptonshire Shared Care Record portal. This would enable staff to access the most up-to-date versions of RESPECT forms, supporting better-informed decision-making and continuity of care.

It was anticipated that, if successful, the initiative would be rolled out across Northamptonshire, potentially improving access to vital care planning information across care homes countywide.