Catherine House 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 with advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment in April 2022, we rated this key question as Requires Improvement. We served a Requirement Notice for breach of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Regulation 12: Safe care and treatment.

During our responsive follow up assessment in September 2022, we assessed that improvements had been made but we did not re-rate the service.

At this assessment, the rating has changed. 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.

At our last assessment in April 2022, we found patient’s needs were not always assessed, and care and treatment were not always delivered in line with current legislation, standards and evidence-based guidance.

During this assessment, we found the service made sure people’s care and treatment were effective. They appropriately checked and discussed people’s health and care needs with them.

Feedback from people using the service was positive. People 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 people’s health, care, and wellbeing needs during health reviews. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. We saw evidence of audits of social prescribing, which showed positive outcomes for people.

As part of our assessment a number of set clinical record searches were undertaken by a CQC GP Specialist Advisor. The search criteria is freely available for the service to access at any time.

We identified during the clinical searches that there were effective reviews and monitoring of patients with asthma and those prescribed disease modifying anti-rheumatic drugs (used to treat autoimmune diseases, particularly rheumatoid arthritis). However, improvements were required in other areas.

We found that 29 patients on a nonsteroidal anti-inflammatory drug (used to reduce pain, fever, and inflammation) in people aged over 65 years or 75 years, had not been prescribed a proton pump inhibitor (PPI - used to protect the stomach lining when taking nonsteroidal anti-inflammatory drugs (NSAIDs), which can cause ulcers). Of the 5 patients records we reviewed, 2 showed as of concern.

People prescribed Aldosterone antagonists (prescription medicines that block the action of aldosterone, a hormone that causes the body to retain water and sodium), did not always have the appropriate blood tests recorded routinely in their records. Of the 5 patients records we reviewed, we found 2 patients out 3 had not had updated results recorded.

We reviewed the records of people with diabetes who had not had appropriate blood test monitoring within the last 12 months. Of the 5 patients records we reviewed, we found patients had updated results recorded. However, 1 patient did not have a recent blood pressure reading.

Following our clinical searches, the provider sent us evidence of the actions they had implemented in response to our findings. This showed the patients clinical records had already been reviewed (showing these test results were available at the time of our searches), as well as people having attended appointments for reviews, required testing and commencement of PPI’s (where appropriate). Where patients had not yet received testing, this was due to their preference for the date of the appointment time (no later than the middle of September) or due to a history of non-compliance by the patient despite the service attempting to address this.

The service always 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. They worked to develop evidence-based good practice and standards.

Clinical staff had access to relevant national and formulary guidance, as well as local policies/guidelines and used this information to help ensure that people's needs were met.

Staff told us they received regular updates from leaders at the service. Where there were changes in process guided by learning at the service, staff told us that they were informed and involved in implementing changes.

We identified during the clinical searches that there were effective reviews and monitoring of patients following receipt of Medicines and Healthcare products Regulatory Agency (MHRA) alerts.

Staff were aware of the need to complete accurate and full records, which meant information did not need to be repeated by patients.

Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. Care and treatment for patients in vulnerable circumstances was coordinated with other services. There were established pathways for staff to follow to ensure patients’ needs were met.

There was no feedback of concern in relation to how staff, teams and other services worked together from partner organisations.

The service ensured that care was delivered in a coordinated way and took account of the needs of different patients, including those who were potentially vulnerable because of their circumstances.

There were clear and effective arrangements for booking appointments and transfers to other services.

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.

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 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. The provider submitted evidence of clinical audits. These covered medicines, health conditions and improving uptake for childhood immunisations, which they had carried out to improve outcomes for people. Leaders and staff told us that audits were discussed at clinical meetings; this was confirmed in the minutes of the meetings we reviewed, which showed the findings were shared and learning outcomes/changes to practice or policies/procedures were cascaded to staff. Quarterly data from the NHS Digital Cervical Screening Dashboard for the six quarters up to Quarter 1 of 2024-25 confirmed that the service had consistently performed above the local Integrated Care Board (ICB) average for both age ranges in relation to cervical screening. The service had not always achieved the average national targets for childhood immunisations. However, evidence showed childhood immunisation rates in Totnes had historically been below national targets. Recognising the importance of protecting children against preventable diseases, Catherine House Surgery had invested considerable effort into increasing uptake. During 2024-25, the service delivered a targeted programme of initiatives, centred on a dedicated Quality Improvement Project. The project combined community engagement, tailored reminder systems, proactive follow-up of missed appointments, and close collaboration with wider healthcare partners including health visitors and school nurses to maximise vaccination coverage. The results showed that between March 2024 and March 2025, there was a notable rise across all childhood immunisation indicators, ranging from an increase of between 2-10% in uptake rates. Data for 2025 show these improvements are being sustained.

Patients did not raise any concerns regarding the service seeking their consent to care and treatment.

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

Consent documentation in relation to minor procedures was appropriately recorded and documented.

Relevant staff had been provided with training in the Mental Capacity Act. The service monitored the process for seeking consent appropriately and patient record searches demonstrated that consent was recorded appropriately. We reviewed Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions for 5 people and found 3 were maintained in in line with relevant legislation. Where they were not maintained appropriately, it was identified that these forms had been completed by secondary care services. The provider was considering an audit of DNACPR records to determine if lessons needed to be shared with secondary care services.