Dr Jude's Practice - Riverside & Picton

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

At our last inspection we rated this key question as requires improvement. At this assessment, the rating has changed to good. We assessed all quality statements within this key question. People participated in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving between services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people and took decisions in people’s best interests where they did not have capacity.

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 previous inspection, this key question was rated as requires improvement because the practice’s achievement in cervical cancer screening and childhood immunisations continued to be below nationally set targets. Although they were still lower than average, sufficient improvements had been made, and the rating is now good.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Feedback from people was positive. They felt involved in assessments of their care needs and were confident that staff understood their individual and cultural preferences. Staff we spoke with understood the local community and had received training to support the population they served. Staff checked people’s health, care, and wellbeing during health reviews. For example, we saw that reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or a recall for blood tests and clinical staff took action to undertake opportunistic checks such as blood pressure monitoring or phlebotomy. However, although capable of signposting patients, not all reception staff were formally trained in triage and care navigation. This was being addressed to ensure that opportunities were not missed when directing or re-directing patients. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. A total of 86% of people who responded to the 2025 National GP Patient Survey felt the healthcare professional they saw had all the information they needed about them during their last general practice appointment compared with the local result of 93% and the national result of 92%.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. Systems such as policies and procedures, clinical and non-clinical templates were in place to ensure staff were up to date with national guidance, evidence-based good practice and required standards. Staff consulted and followed NICE guidance and British National Formularies (BNF) when making decisions about care and treatment. They attended meetings and received appraisal and supervision. Clinical staff had time factored into their days to deal with administrative tasks and non-medical staff had support from GPs in the building daily. Staff we spoke with provided examples where guidance had been followed to improve outcomes, for example when undertaking medicine reviews and reviews of patients with long-term conditions.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. All staff within the organisation were trained to do all tasks such as workflow, scanning, referrals, repeat prescribing and patient registration to ensure adequate cover for planned or unplanned leave. The practice worked with other services to ensure continuity of care. Leaders and staff collaborated closely with colleagues in the local Primary Care Network (PCN) to meet the needs of the patient population.

Multi-disciplinary team meetings were held on a regular basis so that when people received care from a range of different staff, teams, or services, such as those receiving treatment from secondary services or shared care, this was co-ordinated. Shared care agreements were in place to ensure that prescribing arrangements between primary and secondary care were professionally managed. Staff worked closely with all agencies involved in a person’s care to ensure the best outcomes and smooth transitions when people moved between services.

At our last inspection, we recommended that the practice continue to improve the uptake of cervical cancer screening and childhood immunisations. At this assessment, cervical screening uptake remained below the expected 70%, with scores of 53.3% and 56.7%, but had improved since our last inspection. We discussed this with the newly appointed practice nurse and saw the practice had actions in place to improve uptake with a documented improvement plan which was being monitored. Improvements currently included providing additional cervical screening clinics and using every opportunity to educate patients, recognising the challenges of their transient population.

Childhood immunisation uptake was between 63% and 80%, which was below the expected 90%, but had improved since our last inspection. A documented improvement plan was being monitored and staff demonstrated how they continued to monitor uptake and actively encourage attendance through patient recalls, opportunistic conversations and health promotion. The practice also offered Saturday morning appointments to improve access and had ongoing plans to improve uptake in partnership with the PCN.

Staff supported local and national priorities to improve population health, including smoking cessation and weight management. People living with long-term conditions received regular monitoring and were referred or signposted to local support services for information, advice and education. Staff also encouraged people to make healthier lifestyle choices to help maintain their health and wellbeing and reduce the risk of deterioration.

The service routinely monitored people’s care and treatment to continuously improve it. They sought assurance through a series of key performance indicators and quality improvement activity. The practice was able to demonstrate improvements through audits which they shared during the assessment. Positive outcomes were demonstrated through improvements in patient experience and GP practice indicators. Leaders demonstrated that monitoring and improving outcomes for patients was important to them and they used information and data to drive improvement. There was evidence of clinical, non-clinical and medicines audits conducted to improve outcomes for patients.

People who used the service felt they could make an informed decision about their care and treatment because they had been provided with the information needed to support them to do so. The 2025 National GP Patient Survey showed that 71% of patients who responded felt involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment, which was lower than the local result of 82% and the national result of 91%. However, staff we spoke with demonstrated the importance of ensuring that people understood what they were consenting to and the importance of obtaining consent before they delivered care or treatment. Clinical staff had received training in the Mental Capacity Act and provided examples of where consent had been discussed and explained in the person’s language of their choice. There was evidence that alerts had been added to the patient record system and conversations had been recorded when patients’ last wishes were discussed. Relevant information was demonstrated in the care records of patients who did not have capacity to make decisions.