Southway 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 4 quality statements from this key question. We found there was limited monitoring of the outcomes of care and treatment, and patients’ needs were not always assessed and care and treatment was not delivered in line with current legislation, standards and evidence-based guidance.

This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patient feedback via the 2024 National GP Patient Survey (GPPS) indicated 75% patients felt their needs were met during their last general practice appointment. This was below local averages of 92% and the national average of 90%.

Staff told us the needs of carers of people using services were assessed and support offered and we noted 863 (15%) carers were registered at the practice. However, leaders told us that none of the 53 patients on the mental health register had an up-to-date care plan. The provider had employed an external company in April 2023 to support with this and this year they had a plan to introduce a new recall system. We requested the practice provide us with the overall number of patients on the learning disability register and the number of these patients who had up to date health checks between 2023 and 2024. The practice could not provide this information at the the time of the assessment. However, following the assessment, the practice told us 41 out of 49 patients on the learning disability register had received an annual health check in the year 2023/24, and as at 2 December 2024, 25 out of 50 patients had received a health check. We also found 11 staff members had not completed training in learning disability and autism, including how to interact appropriately with autistic people and people who have a learning disability (a legal requirement introduced in July 2022 as part of the Health and Care Act 2022). We noted a further 11 staff members completed this training after the assessment.

There were referral pathways to make sure patients’ needs were addressed. For example, there was a clear system for making two week wait referrals and a process to monitor and follow these up to avoid delays. We noted from the significant events log there had been 4 events of a delayed urgent referral in 2022 to early 2023. However, there had not appeared to be any further events logged after January 2023 which demonstrated the new system worked more efficiently. Staff had a process to use codes, alerts and flags on patient records to ensure patients’ communication, disabilities and any impairment needs were highlighted for staff to tailor patient care.

Patient feedback via the 2024 National GP Patient Survey (GPPS) showed 87% respondents felt the healthcare professional they saw had all the information they needed about them during their last general practice appointment. This was in line with local and national averages.

Staff told us they were provided opportunities to keep up to date with current guidelines and changes to evidence-based care and treatment and we saw some evidence this had been discussed in clinical meetings. However, our remote searches identified a lack of oversight of some long-term condition management to ensure evidence-based care and treatment was given to patients within appropriate timeframes.

The remote searches undertaken of the practice’s clinical patient records system identified monitoring of patients with some long-term conditions were not always followed in line with current legislation, standards and evidence-based guidance including from the National Institute for Health and Care Excellence (NICE), referred to as NICE guidance. For example, searches identified 10 patients as having a potential missed diagnosis of diabetes. We reviewed 5 of these patients in detail and found 4 appeared to have had a missed diagnosis and had not been followed up. Searches also identified 640 patients were on the asthma register, of the 640, 61 patients (9.5%) had been prescribed 2 or more courses of rescue steroids in the last 12 months. We reviewed 4 of these patients in detail and identified none had been followed up to check their response to treatment following exacerbation of their asthma within a week (as required by NICE guidance) and three had not had an annual asthma review in the last 12 months. A review of these patient records also identified 3 examples of limited or no documentation provided by the authorising GP when prescribing medicines.

Members of the Patient Participation Group (PPG) told us they felt positive about working with the practice and felt the practice would engage well with them and keep them informed about future developments. However, they advised because they were so newly formed, they were unable to provide further comment on this currently. Patient feedback via the 2024 National GP Patient Survey (GPPS) indicated 59% respondents said they have had enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illness. This was below the local average of 71% and national average of 68%.

Staff feedback was mixed. Most staff told us they felt leaders at the practice were team-centred and offered a supportive working environment. However, some staff told us not everyone were offered opportunities to attend meetings and felt this would improve overall communication from leaders as well as share learning across the practice.

Feedback from partners was limited. However, we did receive mixed feedback about the care and support provided to residents at a local care home. For example, some feedback highlighted a lack of continuity of care for residents and expressed a disappointment that a weekly ward round ended in December 2023. However, feedback also shared that the practice carried out annual health checks and referrals to specialist services was completed when required.

The provider had some processes for working with agencies to manage care, for example, there were systems to share information about patients with other services. However, we were not assured the practice was attending multi-disciplinary meetings with external agencies such as district nurses, palliative care, health visitors or local safeguarding leads. For example, the practice carried out safeguarding discussions within their internal clinical governance meetings but there was no reference to other agencies being present or being liaised with.

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.

Patient feedback via the 2024 National GP Patient Survey (GPPS) indicated 81% respondents had confidence and trust in the healthcare professional they saw or spoke to during their last general practice appointment. This was below the local average of 94% and national average of 92%. However, we received feedback from a local care home who told us residents were offered annual health checks.

Feedback from staff and leaders was positive about monitoring and improving outcomes. Staff encouraged patients to attend for screening and childhood immunisations and patients who did not attend were followed up. Leaders told us they undertook quality improvement audits and used the information to make improvements.

The practice had a programme of quality improvement activity which included carrying out regular audits to review the effectiveness of systems as well as care and treatment provided. For example, reviewing new cancer diagnoses over the preceding 12 months to determine the method of diagnosis and ensure correct referrals had been made. However, we noted this programme was only recently implemented and therefore provided limited evidence of quality improvement at this stage. We also found that, prior to our assessment, the practice had not carried out prescribing audits for the non-medical prescriber to ensure they were prescribing safely

Published and verified data by UK Health and Security Agency (UKHSA) from March 2023 showed the practice met all 5 child immunisation targets, and 4 of the 5 met the 95% World Health Organisation additional target. However, the UKHSA data from June 2023 showed the practice did not meet the minimum 80% target of eligible patient uptake of cervical screening. The practice uptake as of June 2023 was 68%. The practice acknowledged the need for continued improvement to cervical screening and provided us with recent unverified data which showed the screening carried out in the last 3 years 6 months for 25–49 year olds was 95% and screening carried out in the last 5 years 6 months for 50-64 year olds was 93%.

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.