Woodstock Bower 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

People were involved 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 when making decisions in people’s best interests where they did not have capacity.

This service scored 79 (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 ensured people’s care and treatment were effective by assessing and reviewing their health, wellbeing and communication needs with them. Over the past 12 months, the provider had carried out a wide range of audits to identify gaps in systems and took action to ensure the correct processes were in place to support effective care and treatment.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs.

The National GP Patient Survey results showed that 93% of patients felt that the healthcare professional they saw had all the information they needed about them during their last GP appointment. This was comparable to the local and national averages of 92%.

Reception staff were aware of the needs of the local community and used digital flags within the care records system to highlight any specific individual needs. Staff checked people’s health, care, and wellbeing needs during health reviews.

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. For example, the practice engaged in a targeted initiative, designed to identify patients with atrial fibrillation (AF) and reduce the risk of stroke.

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.

Individually clinicians kept up to date with legislation and current evidence-based good practice and standards.

We carried out a series of clinical searches to assess monitoring and care quality for certain long-term conditions. Overall, the management of long-term conditions was effective, with evidence of appropriate monitoring and follow-up across hypothyroidism, diabetes, and chronic kidney disease. Appropriate monitoring of patients with asthma was mostly appropriate. The timely approach to following up patients following an asthma exacerbation was discussed with the provider. Immediately following the assessment, the provider informed us of changes implemented to improve this.

We carried out a clinical search for patients having a potential missed diagnosis of diabetes. The systems to identify these patients and make sure they were offered the appropriate investigation, treatment and monitoring were effective.

During the assessment, feedback was provided to the provider confirming that no concerns regarding patient harm were identified. However, a small number of issues arising from the clinical searches were highlighted for the provider to review and address as part of ongoing quality improvement.

The service worked effectively across teams to support people and ensured information was shared so individuals did not need to repeat their story when moving between services. Staff had timely access to the information needed to assess, plan, and deliver care, including when tasks were delegated to other providers.

Partner organisations gave positive feedback, reporting the practice’s collaborative approach. They described staff as compassionate, committed, and focused on achieving the best outcomes for people.

The service demonstrated a proactive approach to supporting people to live healthier lives and reduce their future need for care and support. Staff consistently identified individuals who may be at increased risk, including people in the last 12 months of life, those experiencing health inequalities, people at risk of developing long‑term conditions, and those with caring responsibilities. They took appropriate action to address these risks and worked collaboratively with other professionals and services to ensure people received timely and tailored support.

The practice had developed strong and sustained links with local communities to support people to lead healthier lives. For example, they collaborated with a Charitable organisation to host the ‘Purple Bus’ Cancer Awareness service on site, enabling patients and local residents to access free emotional, financial and practical support and information in a familiar setting to reduce health inequalities. The practice supported the visit by providing parking and logistical help, offering reception space for charity representatives, and assisting with the distribution of information and engagement materials.

The practice carried out targeted outreach at a local mosque. During Friday prayers, staff promoted flu vaccinations, NHS health checks and general health advice to Pakistani, Indian and wider Asian communities. This contributed to measurable improvements in health outcomes, including an 18.7% increase in flu vaccination uptake compared with the previous year and a 31% rise in NHS health‑check attendance among Pakistani patients. The provider told us they planned engagement activities, including additional sessions at the mosque after Ramadan and outreach with a local Slovak church to support other underserved populations.

In addition to practice‑led and collaborative initiatives, staff contributed to national public‑health priorities. This included delivering and promoting programmes such as smoking cessation support and healthy‑weight initiatives to help improve population health outcomes. The practice advertised The NHS Health Check on their social media pages and their website. It detailed the benefits of the check and the offer to have this at this practice. At the time of the assessment this had been offered to all eligible patients. 506 had been completed, 904 declined and 398 had not replied.

Staff also provided holistic and personalised support through roles such as the social prescriber, a specialist pain‑management social prescriber and an Admiral Nurse, helping ensure people received coordinated and tailored guidance based on their health and wellbeing needs.

The service routinely monitored and had effective systems to monitor clinical outcomes and used findings to drive improvement. Regular audit activity led to measurable changes in care. For example, the provider had identified asthma management as requiring improvement. It was evident the practice had strengthened staff skills through external specialist training and enhanced pharmacist‑led reviews. A proactive alert system had recently been introduced and included the identification of patients prescribed two or more SABA inhalers (inhalers used to treat acute asthma symptoms) within 12 months, prompting timely asthma reviews. As a result, the number of high‑risk patients reduced from 82 in November 2024 to 37 at the latest review.

Ongoing monitoring through prescribing data and multidisciplinary review ensured sustained improvement. From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. Where the provider had identified that patients did not, they put measures in place to address this.

The practice monitored childhood immunisation uptake and used the findings to drive improvement. They met WHO targets for one vaccine and achieved uptake above 90% for two others, with the remaining two slightly below target at 83% and 89%. Data for 2024–2025 showed small but positive increases across four vaccines. Leaders recognised local challenges and worked with Healthwatch, NHS England, the Immunisations Lead and a company that provided NHS services to explore more flexible, community‑based delivery options.

The practice also monitored cervical screening uptake and took action to improve performance, as outlined in this report. Data submitted by the provider confirmed that the practice was exceeding both national and PCN averages, with its internal reporting system recording a 94% uptake for the cervical sweep component of cervical cytology. Between April 2025 and the date of the assessment, overall cervical screening uptake at Woodstock Bower Surgery increased from 47.54% to 69.04%, representing a 45% relative improvement.

The practice demonstrated that they continued to act opportunistically and seek further options to increase uptake.

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

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Audits to check consent was appropriately recorded. No concerns were identified in the audit records.

Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.