Hodford Road 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 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.

At our last assessment under the previous provider, we rated this key question as Requires Improvement. At this assessment, the rating has changed to Good.

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.

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 positive and they felt involved and understood. This was reflected in the 2025 GP Patient Survey where 96% of patients felt their needs were met during their last appointment. This was above the local average of 88% and national average of 90%. Staff used digital flags to highlight specific needs, such as the requirement for extended appointments or for an interpreter to be present.

During our assessment, a CQC GP specialist advisor reviewed patient records to check the management of patients with long-term conditions at the practice. These searches undertaken were visible to the practice. One search we looked at related to pre-diabetes checks. We conducted a search for patients with the possible diagnosis of diabetes following a blood test result and identified 4 patients out of 4495 patients where there was a potential missed diagnosis of diabetes. We reviewed these 4 patients and found that 1 of the patients had been coded as suspected diabetes incorrectly when they should have been recorded as having diabetes. The practice told us that it would review this patient.

We reviewed patients with acute exacerbation of asthma who were prescribed 2 or more courses of rescue steroids in the last 12 months and found patients were appropriately monitored. We reviewed patients with Chronic Kidney Disease (CKD) stages 4 or 5 and found that all patients were appropriately managed. We reviewed patients with hypothyroidism and found that patients with outstanding monitoring had been contacted by the practice. We found that the practice was effectively managing patients with type 2 diabetes where there was a risk of diabetes complications due to high blood glucose levels.

We saw evidence in our clinical searches that medication reviews were being completed comprehensively.

The practice maintained a list of patients who had carers and where additional assistance was needed, carers were signposted to appropriate services. Staff appropriately managed long-term condition monitoring including arranging routine tests and follow-up appointments. Regular reviews were conducted to ensure ongoing monitoring and care. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Updates were communicated with staff and meetings included allocated time for discussing new guidance.

Clinical records we saw demonstrated care was provided in line with current guidance.

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 necessary information, supported by clear policies and procedures. The practice was part of a Primary Care Network (PCN) and worked collaboratively to meet the needs of their patient population. Staff maintained regular communication to ensure continuity of care, including where clinical tasks were delegated to other services.

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 focussed on identifying risks to patients’ health, including those with caring responsibilities, patients at risk of developing a long-term condition and those in the last 12 months of their lives. Staff aimed to initiate conversations with patients early, where appropriate, to ensure care planning was in place. The practice worked with palliative care services, district nurses and discussed preferred place of care.

Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. Staff encouraged patients who smoked to consider smoking cessation and discussed health risks. Patients were signposted to local smoking cessation services, and the practice told us they contacted patients annually to consider available support.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

We saw evidence of 3 Two-cycle audits completed by the practice to find ways to improve the quality of patient care, with changes being implemented in response to findings and outcomes reviewed to ensure improvements were sustained. For example, the practice completed a full-cycle audit to review and effectively embed the Pharmacy First service into the practice total triage model, using analysis and real-time feedback during daily triage. Following audits, the practice saw improvements, including improved appointment availability and reduced pressure on duty doctors. Learning was also shared with the wider Primary Care Network.

The practice had not met the World Health Organisation (WHO) national target of 95 percent for all five key childhood immunisation indicators between 1 April 2023 to 31 March 2024. Uptake ranged between 85.2% and 92.7%. The practice was also below the 80% national target for cervical screening as of 30 June 2023, with 59.6% of people receiving an adequate screening test. The practice acknowledged shortfalls with uptake and explained actions taken to support improvement and reduce the barriers to uptake. Designated members of staff maintained an up-to-date list for childhood immunisations with monthly checks and followed up with parents where appointments were missed, including multiple reminders and failsafe checks conducted by staff. The practice followed the NHS Cervical Screening Programme call and recall system to ensure all eligible patients were invited with up to three reminders issued centrally. An internal failsafe tracking process was in place to monitor results and follow up where necessary. The practice participated in the YouScreen self-sampling research project for patients who had not attended routine screening appointments, resulting in improved screening uptake figures. Staff sent text messages containing information and a self-booking link to encourage participation. Staff would also routinely use consultations, repeat prescription reviews and results discussions to promote and book appointments.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. Clinical staff had appropriate training on the Mental Capacity Act.

We did not always see that Do not attempt cardiopulmonary resuscitation (DNACPR) decisions had been correctly coded in clinical records. During our clinical searches, we found 1 patient with a DNACPR code in their clinical records. The practice told us that it used an external system to record universal care plans which was accessible by their parties. The practice told us that decisions were recorded in these care plans and were made in line with relevant legislation.