Knoll Medical 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 patients in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed patients’ 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 83 (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 always made sure patients’ care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them.

The provider had utilised a multidisciplinary team to review patients with very high appointment use. This review had identified reasons behind recurrent attendance, and the provider had worked with patients to produce personalised care plans to best support individuals. There was continuity of care for these patients who were booked with the same clinician whilst also utilising other services, such as fall prevention clinics, occupational therapists, physiotherapists and social prescribing, as well as local charity groups where appropriate.

The provider separated patients into 2 groups: those with 20 or more attendances per year and those with 40 or more attendances per year. From the implementation of this project, there was a notable decline in attendance for both groups. Unverified data showed patients with 20 or more attendances reduced from approximately 30 per 1000 patients to 14 per 1000 patients. Patients with 40 or more attendances per year reduced from approximately 50 per 1000 patients to 15 per 1000 patients. These figures were significantly below local and national averages.

This project resulted in personalised support and earlier identification of unmet needs. There was also more effective use of appointments at the practice.

Feedback from patients using the service was positive. Patients felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community. 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 patients’ health, care, and wellbeing needs during health reviews. The provider had effective systems to identify patients with previously undiagnosed conditions. Staff could refer patients with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The service always planned and delivered patients’ 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.

Systems were in place 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.

The practice had identified diabetes management as a priority area for improvement as a significant number of patients were not attending their annual review. A survey was sent to all patients to identify barriers to attendance. The survey found that whilst patients understood the importance of attending for their reviews, barriers such as getting time off work, inconvenient appointment time and mobility and health concerns often prevented patients from attending. Some patients said they did not receive appointment reminders and would appreciate a simplified booking process. The practice also reviewed their own processes and found that the majority of reviews were undertaken by 2 of the practice nurses.

The practice took action, including amending the recall process to the patients’ birthday month, increased the number of appointments, added more availability at earlier and later times, and offered support for patients with mobility and health related barriers. Clinicians developed guidance so that patients were directed to the right person, whether this be a pharmacist, practice nurse, or GP.

These changes resulted in an increased number of patients attending their annual review. There were 951 patients on the diabetes register. Between April 2024 to March 2025, 423 patients attended for their annual reviews. Following the implementation of these changes, 686 patients attended for their review between April 2025 to 26 March 2026 (due to the timing of our assessment, these figures do not include the total up until the end of March 2026).

These changes also resulted in improved outcomes for patients. The average HbA1c for these patients reduced by 2.8mmol/mol (HbA1c is a measure of a person’s blood glucose level over the past 2 to 3 months). Other improvements were also seen including an increase in the number of patients who had their diabetic foot checks from 42% to 100% and the number of patients with cardiovascular disease who were prescribed a statin increased from 94% to 100%.

Following the implementation of the changes the practice conducted another survey. This found a decrease in the percentage of patients describing inconvenient appointment times and difficulty taking time off work as barriers to attendance. There was also a decrease in the percentage of patients who said they did not receive an appointment reminder. The practice identified that further work was needed to reduce transport difficulties, and mobility and health concerns as barriers.

The service worked well across teams and services to support patients. They made sure patients only needed to tell their story once by sharing their assessment of needs when patients moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver patients’ 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 service always supported patients to manage their health and wellbeing to fully maximise their independence, choice and control. The service supported patients 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, 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 service routinely monitored patients’ 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 patients themselves.

UK Health Security Agency (UKHSA) for the period of 1 April 2024 to 31 March 2025 showed the practice had met the World Health Organisation (WHO) minimum recommendations for uptake of 4 of 5 indicators relating to childhood immunisations. One indicator was below the minimum recommendation of 90%. This was the percentage of children aged 5 who had received immunisation for measles, mumps and rubella (MMR) where uptake was 83%. Uptake within the practice population was higher than the local average (77.7%) and in line with the national average (83.7%).

To address the uptake of childhood immunisations the practice had systems to identify children at registration who had not had all their immunisations and appointments were proactively made when babies were born. The provider contacted patients who were hesitant to take up immunisations to discuss their concerns and placed alerts on patients records so that opportunistic appointments could be made when patients had appointments for other matters.

NHS England data from June 2024 showed the practice had not met national targets for the uptake of cervical cancer screening. Screening for eligible patients aged 25 to 49 years was 69.5% and for eligible patients aged 50 to 64 years was 78.3%. The target for both age groups was 80%. The practice’s performance was higher than local (61.6%) and national (68.8%) averages.

To address the uptake of cervical screening, the practice offered home kits where patients could carry out sampling themselves. Patients who were housebound or patients with a learning disability, were offered a home visit. Patients were given the opportunity to discuss concerns with a member of staff and reminders were sent using different methods of communication.

The service told patients 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.