Melrose Surgery, Reading Also known as Melrose 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

The practice had systems and processes to keep clinicians up to date with current evidence-based practice. We found that patients’ immediate and ongoing needs were fully assessed these included interventions required to ensure effective care was delivered.

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.

People who were most clinically vulnerable were prioritised and the practice worked with other healthcare professionals to deliver a coordinated package of care.

Practice staff told us they shared clear and accurate information with relevant professionals when deciding care delivery for patients with long-term conditions. Staff also told us they were confident patients’ care records and prescriptions were updated to reflect any extra or changed needs as requested by the patient, their families or secondary care.

The provider had effective processes to ensure an ongoing needs assessment. The practice carried out structured annual medicines reviews for patients with long-term health conditions who were invited in for your annual review during their birthday month. The practice had a programme of both clinical and non-clinical audits that were used to monitor quality and make improvement when actions were identified. All trainee GPs were involved in undertaking clinical audits as part of their training. We saw the practice had 10 ongoing quality improvement audits at the time of the assessment. For example, a 2-cycle antibiotic audit and audit for monitoring patients with thyroid papillary cancer. The practice was also working with the Primary Care Network (PCN) on a diabetes remission programme to create awareness among patients who have recently been diagnosed with diabetes.

Feedback from leaders showed they worked to ensure all clinical correspondence and tasks were up to date. They told us they had a system to ensure where staff recently left the practice their task were redistributed. The practice leaders told us they had acted upon resolving any pending tasks previously allocated to the person that no longer worked at the practice.

The series of searches we completed on the practice’s clinical records system to review if the practice was delivering care and treatment in line with best practice showed patients prescribed high-risk medicine or medicines that required regular monitoring was in the majority of cases, completed according to best practice guidance. There was a system and named staff who oversaw the different audits to support safe care and treatment. The clinical searches did not identify any significant gaps in the monitoring of patients with long term conditions. However, in some cases care and treatment was not delivered in line with current legislation, standards, and evidence-based guidance. We reviewed a sample of 5 out of 22 patients with asthma, who have had 2 or more courses of rescue steroids in the last 12 months and found none had been followed up. We identified patients with chronic kidney disease stage 3, 4 or 5 who had not had the required monitoring in the last 9 months. The practice responded promptly to our feedback. They submitted a comprehensive response shortly after the review with the details of work that clinical staff had completed regarding the identified patients, including recalling patients for monitoring and reviews, whilst strengthening the recall systems and processes to enable them to deliver safe care and treatment or making improvements to their systems and processes to enable them to deliver safe care and treatment.

People has access to appropriate health checks and assessments, and they were directed to relevant services when they needed extra support. For example, patients assessed as at risk of developing a long-term condition. People were encouraged to be involved in monitoring and managing their own health and were being referred, if appropriate to the social prescriber who worked with all member practices in the local PCN.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.