Holmcroft 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

This is the first inspection for this service since its registration with CQC 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. Systems to support people to live healthier lives could be strengthened. For example, cervical screening uptake remained below the national minimum target of 90%. The uptake of childhood immunisations for 5-year-olds were below the national target. However, leaders were aware and targeted improvement plans were discussed and monitored by the clinical team. Leaders reported on additional workload due to the difficulties trying to ensure there were robust shared care agreements in place for their patients with some secondary care providers. Clinical and multi-disciplinary meetings were in place and there were systems in place to review people at the end of their life. Systems were in place to obtain consent to care and treatment. There were systems in place to support people to be involved in assessments of their needs. Clinical records we saw demonstrated care was provided mainly in line with current guidance. This key question has been rated as good.

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 service 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 mixed. There were systems in place to support people to be involved in assessments of their needs. Staff understood patients individual and cultural needs and there were policies and procedures in place including training to provide further support. 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. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The service did not consistently plan and deliver people’s care and treatment with them in line with current evidence-based good practice and standards. Clinical records we sampled showed not all patients’ care and treatment was monitored in line with current guidance. The practice agreed to review this small number of people. Systems were in place to ensure staff were up to date with evidence-based guidance and legislation.

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.

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. These included for example, social care, physiotherapy, safeguarding teams, occupational therapy, and mental health support. Leaders reported on additional workload due to the difficulties trying to ensure there were effective shared care agreements in place for their patients with secondary care providers. The issues with the outstanding shared care agreements were highlighted to the integrated care board medicines optimisation team.

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 focused on identifying risks to patients’ health, including those in the last 12 months of their lives, people 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. People using the service had access to health promotion and education to support them, available within the practice and the practice website. This was provided in various formats such as screening and vaccination programmes as well as during face-to-face consultations. The practice had systems in place that enabled staff to signpost people to tertiary services and carer group support. The practice signposted people to community services as well as self-help groups and advocacy services.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. The practice had not met the national minimum targets for cervical screening. We noted a fall in the uptake of this screening as a trend over time. The clinical team had identified the younger cohort were less likely to attend for screening appointments. Leaders and clinical staff told us the lower uptake of cervical screening had been discussed and action plans implemented. The clinical lead was in the process of having conversations with faith leaders about attending faith establishments with a heath care worker of the same culture to encourage an uptake in cervical screening. Childhood immunisations were within target except for children aged 5 years with the second dose of measles, mumps, and rubella. This was very slightly below the minimum target of 90%. The service took part in the Quality Improvement Framework (QIF) initiatives set by the ICB including those for 2024/25. These continued to focus on following national and local key priorities. For example, long term conditions, screening, management and quality improvement in diabetes, raised blood pressure and other conditions, in palliative care (including supporting ICB End of Life programme with embedding use of Recommended Summary Plan for Emergency Care and Treatment (ReSPECT)/advanced care plans) and to increase the identification and prevalence rate of chronic kidney disease (CKD).

The service told people 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. Clinical staff received Mental Capacity Act (MCA) training as per their policy.