School House 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 assessed all quality statements for this key question and rated the practice good for providing effective services. We found care was delivered and reviewed in a coordinated way when different teams, services or organisations were involved. Staff were passionate about supporting patients to live healthier lives and where possible, reduce their future need for care and support. However, we found the practice could improve their systems and processes to monitor patients’ health in relation to their long-term condition.

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.

We found most people were positive about the experience of care and treatment they received at the practice within the last 12 months. We saw positive comments about the practice being supportive about general health and offering good advice about wellbeing. However, there was a negative comment about delayed or missed medication reviews.

Staff we spoke with were aware of the needs of their patients and could demonstrate changes had been made to suit patient needs in their population. Leaders and staff told us the practice used codes and alerts on the patient record to highlight people’s needs. The practice had systems and processes to identify people’s needs and preferences during the registration process. Staff told us they checked people’s health, care, wellbeing and communication needs during health reviews.

There were appropriate referral pathways to make sure that patients’ needs were addressed. There were processes to ensure practice staff could identify patients presenting with symptoms which could indicate serious illness and follow up in a timely and appropriate way. This included a navigation tool used by receptionists, which assisted staff in identifying immediate concerns or red flags and what action to take. Processes were in place to assess patients’ immediate and ongoing needs. This included their clinical needs and their mental and physical wellbeing. However, some of these processes were not working as expected. We found medicine reviews did not always contain information in line with best practice guidance. For example, we found a review that had not considered all of the medicines a patient had been prescribed. We also found patients prescribed medicines for anxiety disorders had not always received a review in line with recommended timelines. Practice leaders demonstrated they took immediate action to further investigate and follow up on these patients. We received a full response from the practice regarding the patients we were concerned about.

We found most people were positive about the experience of care and treatment they received at the practice in the last 12 months. We did not receive any concerns or identify any specific feedback about the practice delivering evidence-based treatment.

Clinical staff we spoke with described how they kept up to date with evidence-based practice. The clinical staff at the practice told us they received information and guidance from the practice manager or GP partners through meetings and emails. Staff also took personal responsibility for keeping up to date. There was regular communication between staff, and we were told a GP was always available if they needed advice or were concerned about a patient.

We carried out a series of searches on the practice’s clinical records system to review if care and treatment was delivered in line with best practice. Our searches indicated a low number of patients potentially at risk due to outstanding monitoring. A further investigation of patients’ records was undertaken to assess the potential risks. We had some concerns around the monitoring and prescribing of medicines, including for patients with long term conditions, where we found national guidance were not always being followed. This included the management of patients with exacerbation of asthma, diabetes, and those taking medicines to control blood pressure. Practice leaders demonstrated they took immediate action to further investigate and follow up on these patients. We received a full response from the practice regarding the patients we were concerned about.

We found most people were positive about the experience of care and treatment they received at the practice in the last 12 months. Feedback we received was positive about clinical correspondence, referrals and communication with secondary care.

Staff described systems to share information between teams and services to ensure continuity of care, such as when clinical tasks were delegated or when people were referred between services. Multidisciplinary teams met regularly to discuss and support vulnerable patients.

We received feedback from partners including the commissioners of the service, NHS Sussex integrated care board (ICB) and Healthwatch. They did not make any comments relating to this quality statement.

The practice had a process and clear audit trail for the management of information about changes to a patient’s medicines including changes made by other services. There was a dedicated GP who processed clinical correspondence, prescriptions, coding and other associated actions. During our assessment, we found no backlogs of information and all test results were reviewed and followed up in a timely manner. We also found referrals to specialist services were documented, contained the required information and there was a system to monitor delays in referrals.

We found most people were positive about the experience of care and treatment they received at the practice with the last 12 months. We saw positive comments about the practice being supportive and understanding. People told us the practice gave advice to support their wellbeing and general health.

All staff demonstrated a passion to support patients to manage their health and wellbeing so they can maximise their independence, choice and control. They told us they wanted to support them to live healthier lives and where possible, reduce their future needs for care and support. They told us that patients had access to appropriate health assessments and checks.

There was a social prescriber who worked at the practice 2 days per week, who supported patients with their wellbeing and could refer to other services. During our site visit, we saw there were leaflets in the reception area with information on smoking cessation, dressing clinics and local organisations who could offer healthy living advice.

We found most people were positive about the experience of care and treatment they received at the practice in the last 12 months. We did not receive any concerns or identify any specific feedback about this quality statement.

Staff and leaders told us about their systems and processes to monitor and improve outcomes. They explained that quality governance was developing, and they were aware of their areas to improve. Since taking over the practice in December 2022, the provider explained one of their focuses was to improve access and therefore outcomes for patients. They told us about the significant piece of work carried out to identify and recall patients who urgently needed to be seen. They were aware of their performance for child immunisations and cervical screening, which were below the target uptake rate. We saw they had developed an improvement plan and appropriate actions, including increasing or reallocating staff resources, adjusting appointment times in consideration of barriers such as work or childcare, and engagement with public health campaigns. Following our assessment, the practice told us their advanced nurse practitioner now completed a full day twice per month dedicated to women’s health.

We found documented evidence of shared learning through complaints and significant events, which improved outcomes for patients. The practice had also introduced a programme of clinical audit and second cycle audits. These demonstrated improvements to the quality of care. This included audits of prescribing and medicines management audits. We were provided with evidence of audits including an audit of patients recently diagnosed with diabetes, audit of deaths and end of life identification, and an audit to assess the quality of diagnosis and actions since new major cancer diagnoses.

We reviewed the practice performance for indicators including prescribing safety, prevention, diagnostics and access. We found the practice was in line with national averages except for child immunisation, cervical screening and the number of patients prescribed dependency forming medicines. The practice was aware of these outcomes and had appropriate improvement plans in place.

We found most people were positive about the experience of care and treatment they received at the practice in the last 12 months. We did not receive any concerns or identify any specific feedback about the people’s experience in relation to consent to care and treatment.

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. Staff told us they were able to adapt information about care and treatment in a way the patient would understand to support them making informed decisions.

Clinicians supported patients to make decisions. Our review of clinical records showed that where appropriate, clinicians assessed and recorded a patient's mental capacity to make a decision. DNACPR decisions were made in line with relevant legislation and were appropriate.