Wetherby Health Centre

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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.

This is the first inspection for this service since its registration with CQC. This key question has been rated as 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 practice made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing, and communication needs with them.

Patient feedback from the 2025 National GP Patient Survey indicated that satisfaction with how the practice worked with them to assess their needs was generally above local and national averages. For example, 89% of respondents reported that the healthcare professional they saw or spoke to was good at listening to them at their last general practice appointment, compared to the local and national average of 87%. In addition, 92% of patients reported that they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment, compared to a local and national average of 91%.

The provider had implemented care navigation processes to assess initial needs and supported this process by the adoption of a care navigation policy and clinical triage processes. Staff were also able to call on for support and advice via the shift lead/duty doctor when required.

Patients with long-term conditions were effectively supported and managed. Clinical records we reviewed during our CQC remote clinical searches showed that care was provided in line with this guidance. Patients with hypothyroidism, chronic kidney disease, asthma, and diabetes were well managed and patients were regularly monitored and reviewed.

The provider had effective systems to identify patients with previously undiagnosed conditions. We examined the potential for missed diagnosis of diabetes, and found that patients had been appropriately supported, reviewed and monitored.

The provider held registers of patients who were vulnerable or needed enhanced care and support such as palliative care patients, or those patients with a learning disability. The provider explained to us that they utilised these registers to effectively manage their care in coordination with other services. Patients with caring responsibilities were also recognised and additional support including reviews and offers of vaccinations were put in place to support them. The provider had also appointed a staff member to act as a carers champion.

We saw that staff from the practice regularly met with others such as palliative care providers and health visitors to coordinate care for those with additional needs. The provider supported patients in a local residential care home, with both GPs from the practice and a primary care network community paramedic assessing needs and delivering coordinated care. Feedback from the home confirmed the effectiveness of this approach to care delivery.

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, although we did see minor issues in respect of asthma care which did not follow national guidance.

We saw that systems and processes were in place to ensure staff were up to date with evidence-based guidance and legislation. For example, the provider held regular meetings such as daily short duration meetings (huddles) where care and treatment could be discussed including guidelines, complex cases and learning. We saw that staff had received advanced training and qualifications which allowed them to give more complex care to patients.

Staff confirmed with us they kept up to date through training and meeting attendance, and told us that the provider was supportive of professional development.

The practice worked across teams and services to support people. We saw that staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support.

The provider worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services such as primary care network staff working within the practice. We saw that the provider had in place processes to ensure the monitoring of referrals to other services including 2-week wait cancer referrals. In addition, following previous referral issues for 2-week waits the provider had introduced a mandatory pop-up prompt to ensure that referrals were appropriately actioned.

The provider liaised with and/or met with other multidisciplinary stakeholders including community and palliative care nurses, health visitors, and safeguarding team members to discuss the care and treatment of vulnerable patients, or those with complex needs.

The provider supported patients to manage their health and wellbeing to maximise their independence, choice, and control. The practice supported patients 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 in the last 12 months of their lives, patients who were at risk of developing a long-term condition, and supporting those with caring responsibilities.

The provider offered patients a range of health assessments which included NHS health checks, new patient health assessments, and learning disability health checks. Specific health clinics and services were available to patients which included a pharmacist diabetic clinic and services to support patients suffering from low level mental health issues. During our CQC remote clinical searches we saw evidence that processes were in place to support patients at risk of developing conditions such as diabetes.

Clinical and front-facing non-clinical staff had been trained and could refer or signpost patients with specific needs to other organisations. As part of their primary care network (PCN), the provider had access to other health and care services such as social prescribers, and a local Leg Club. The latter was an informal leg health clinic where patients could meet for services such as wound dressing and leg health advice, as well as having the opportunity for social mixing with others. Initial, assessment showed reduced demand for wound care appointments at participating practices, and improved patient mood and social connection, and reduced social isolation.

The provider’s website was easy to navigate and gave information to patients regarding common health conditions and options for support. The waiting area also carried information leaflets which patients could access for additional guidance and support.

In addition, we saw that the practice hosted and brought specialist community services into the practice, examples being the hosting of extended hours services delivered by the PCN, antenatal support, and screening for abdominal aortic aneurysms (which checked for swelling in the aorta).

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

We saw that patients with long-term conditions had been well managed and were reviewed appropriately, and that patients in receipt of specific medicines which required regular monitoring had received the necessary testing and monitoring in a timely way. The provider regularly ran searches to identify patients who required monitoring and reviews.

The provider used clinical audits to monitor and improve patient care. For example, the provider had undertaken an audit into high dose opiate prescribing, and participated in external assessments such as a review into the management of chronic obstructive pulmonary disease (COPD). Staff had also devised improvements such as developing a flowchart to support PSA (Prostate-Specific Antigen) testing.

The provider was very slightly below 1 of 2 national targets for cervical screening, and had met another. The latest published screening performance (30 June 2024) showed 79% of 25–49-year-olds and 80% of 50–64-year-olds had been screened against a target of 80% for both age groups. When we discussed cervical screening with the provider, we were told that staff worked hard to engage with patients and promote screening. This included sending innovative reminder cards and birthday cards to patients and developing approaches to dealing with non-responders to invitations. We were also informed by the provider that current unverified data showed that as of December 2025 the provider had screened 78% of eligible patients.

Child immunisation performance was generally satisfactory with 4 of 5 target measures exceeding the 90% minimum target, and 1 measure short at 86%. The provider informed us that they had measures to escalate concerns regarding the failure to vaccinate children or if children missed planned appointments.

Bowel and breast screening rates for patients were above the national average. Bowel screening was at 81% compared to the average of 72%, and patient breast screening rates were 85% compared to a national average of 70%.

Patient responses to the 2025 National GP Patient Survey indicated that they felt they were supported by local services with 74% reporting that they felt they had enough support from local services and organisations to help manage their long-term conditions or illnesses, which was above the local average of 70% and the national average of 69%.

The service told patients about their rights around consent and respected these when delivering person-centred care and treatment.

As part of our assessment, we spoke with clinical and non-clinical staff, and they all had a detailed understanding of consent. Most consent was either implied or verbal, although the practice required written consent for more complex or invasive treatments such as minor surgery. Staff also considered consent issues when providing care to children and young people, and the need to assess the mental capacity of patients to give their consent to care and treatment including referrals. We saw that staff had received appropriate training in the requirements of mental capacity legislation and best practice principles.

During our CQC remote clinical searches and our onsite visits we examined 5 patient records, and saw that ReSPECT forms (Recommended Summary Plan for Emergency Care and Treatment – a document which holds personalised recommendations for a person's clinical care in an emergency), which included decisions related to Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were both accessible to staff, and had been completed in line with relevant legislation.