Sacriston Medical 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. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

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 provider 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 generally positive. The latest National GP Patient Survey results showed that 97% of patients who responded felt ‘involved as much as they wanted to be in decisions about their care and treatment’. This compares to a 91% national and 92% local area average. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs.

Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. 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 practice used the NHS health check proactively to help identify any undiagnosed health problems and take appropriate action as needed. We saw evidence of this including cancer diagnoses and kidney problems. 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. New evidence-based approaches were used to support the delivery of consistent, high-quality care.

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

Staff and leaders were encouraged to keep up to date with research and proactively learn about new and innovative evidence-based approaches that could improve service delivery. For example, we saw this demonstrated within the work the practice did supporting autistic people and people with a learning disability. The practice leadership had worked with external partners and others in this field to develop a bespoke health check for autistic people and people with a learning disability. This work reflected the fact that 1% of patients registered with the practice had a learning disability (approximately 105 patients).

They had developed an inclusion tool for clinical systems to help identify themes regarding patient illnesses and guide towards best treatment. Leaders at the practice worked with local schools, social care workers and others to get to the most appropriate care for patients. Positive outcomes we saw included 4 patients receiving earlier diagnoses of certain conditions like cancer, diabetes and heart disease. This demonstrated the new tool had more positive patient outcomes that the previous processes as they would not have picked up these diagnoses.

We saw evidence of the impact for patients on the introduction of this inclusion tool in 2023; in 2019 there were 54 patients on the LD register but the work that had been done since had seen 107 patients on the register in 2026. The practice told us that as 2025/2026 73.7% of patients on the register (only able to account for patients over the age of 14) have had their annual health checks. Reasonable adjustments are added for each LD patient (depending on each patients individual needs) including home visits for housebound patients, accommodating patient sensory needs (for example booking appointment during known quieter times at the practice), varying when the appointments take place and the practice have set as routine appointment lengths of 30 minutes (but again can be extended dependant on patient need).

The lead at the practice for learning disabilities told us that the work the practice (and PCN) was doing had resulted in a new training post for GP registrars’ – a community LD team post – upskilling and highlighting the necessity for better patient care. Something staff were very proud to support. The impact of this role will be better co-ordination and joined up care for these patients.

A remote review of the patient record system showed that patients received appropriate long-term condition reviews.

The provider demonstrated numerous audits that had been carried out following the 2-cycle method that had a clear positive impact on patients.

For example, the practice had identified a particular course of action clinicians were taking in the treatment of certain bone issues including osteoporosis; the use of a denosumab injection. Longer term audits had been initiated to review the safety of these injections and whether appropriate blood tests were being taken prior and if alongside injections calcium/vitamin D were being prescribed. Initial data suggested an issue regarding the uptake of blood tests at 54% of patients. Changes were made to patient recall systems including the use of amended text messaging and protocols for nurses not to give injection unless blood tests were done prior – there had been a sustained increase to 64% of patients having blood tests. 100% of patients had been prescribed calcium/vitamin D. The practice understands this is a work in progress and are actively reviewing this patient care going forward.

The provider 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 the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. The provider 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 in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The provider 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.

The practice met national targets for screening and immunisations. Data from NHS England (most recently published data was from 2024) shows a 73% coverage rate for women aged between 24-49 receiving adequate cancer screenings against a target of 80%. Unverified data from the practice during the assessment showed the most up to date figure to be 82%. The practice told us they were using social prescribers and care co-ordinators to actively promote screening uptake alongside national and PCN campaigns. Data from the UK Health Security Agency from 2024-2025 showed the rate of children aged between 12-18 months taking at least 1 dose of the MMR vaccine to be above target at 97%. They told us during the assessment that the current figure for 2026 remains at 97%. This compared against the world health organisation target of 95%.

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.

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