The Village Green 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 services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people and considered capacity and legal power of attorney when decisions were being made.At our last assessment, we rated this key question as outstanding. At this assessment, the rating has remained the same.

This service scored 88 (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 always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them. We gained feedback from service users including those who reside in care homes and found people using the service felt they were able to communicate needs and expectations, and these were met and care was often above patient expectations.

The surgery worked around a continuity of care model. This was implemented into practice in March 2025, we reviewed evidence which indicated the practice had worked on the project since 2024, the planning had been clearly focused around patients and worked on the basis that patients would be aligned to a specific/named GP. This clinician took responsibility for overseeing this patient for all appointments (unless an urgent appointment was required), test monitoring and referrals. It was decided that if a GP required more than two contacts with a patient the system would align the patient to that clinician, ensuring outcomes could be more closely monitored for patients. The leadership team had outlined which groups of patients needed to be aligned to a GP first, for example, those with complex health issues. The purpose of this project was to ensure needs of patients were met by a clinician who already knew their story and understood health needs and any protected factors.

The practice had carried out a patient survey approximately 8 weeks after the implementation of the new model, in which patients were given the opportunity to feedback on how they felt their experience had changed. 57% of patients stated they felt more confident in the practice since being aligned with a named GP.

We reviewed a clear implementation plan for this project which was regularly reviewed, with actions clearly documented and aligned to partners. Leaders told us they intended to run a further survey once amendments were made based on the current results.

All staff were aware of the needs of the local community and went above and beyond to ensure patients were able to access any local initiatives, for example patients who may benefit from community groups, such as a gardening project in a local park were sent a text, the information was also shared on practice social medial.

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. An audit was commenced in 2024 which looked at patients who required a digital flag on their records. This was a group of patients who had 3 or more clinical codes. It was highlighted by leadership that this was not being done effectively by staff. Management provided relevant staff with an education session on this issue. It was closely monitored, and two re-audits had taken place in 2025 with numbers increasing significantly from 8 patients to 125. This demonstrated that leaders had ensured changes were embedded into practice, furthermore, ensuring positive outcomes for patients who required this level of coding on records. The practice is continuing this piece of work.

Staff checked people’s health, care, and wellbeing needs during health reviews and signposted appropriately when required. This was highlighted in the National Patient Survey which indicated 87% of patients felt wellbeing was considered during their appointment, the national average being 74%.

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. Staff also utilised external services such as smoking cessation to provide further support to patients who required it. Our clinical searches outlined an effective system for patients with long term conditions; the re-call process was an established system which all staff understood. We reviewed evidence of a cohort of almost 1000 patients receiving intense monitoring for pre-diabetes, these patients were coded and received regular monitoring, health promotion and support from the practice. There has also been a recent quality improvement project carried out around the pre-diabetic letter, which was sent to patients, it was noted that information was not populated accurately, this was corrected by leaders, to ensure that the assessment of this cohort of patients was accurate. Since implementing the new template, the practice has provided evidence with outlines a increase of 28.9% patients being contacted who would not have been without this work.

The provider also ensured this group of patients were given advice on diet and lifestyle and given support in reducing the HBA1C levels. The practice provided us with evidence which indicated from August 2024-2025 a positive trend in HBA1C results following being monitored in this project; 53% of patients who were involved with the project were no longer coded as pre-diabetic.

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. The practice utilised an employed care navigator who strived to enhance the lives of the patient population, we spoke to this member of staff who told us they had chosen to enhance a knowledge of what the practice could utilise for patients with long term conditions.

The service always planned and delivered people’s care and treatment with them, including what was important and mattered to them. The practice ensured patients who required support, such as those who had a palliative diagnosis were offered extra support. Clinical and non-clinical teams had a knowledge of external support service for these groups of patients and did this in line with legislation. They worked to develop evidence-based good practice and standards. Patient safety alerts were acknowledged by a member of the pharmacy team and fed back to staff as a matter of urgency, management then ensured the recall team contacted any patients who may have been affected.

In 2024, the practice responded to a safety alert which affected male patients prescribed sodium valproate. The concern was surrounding potential pregnancy and implications for a baby who may be born whilst a father was taking this medication. At the time of the alert, there was no protocol in place to alert this group of patients, the practice implemented this and embedded it within practice, this risk is now discussed with all patients newly prescribed this medication. For those patients who were taking Sodium Valproate prior to the alert, a text message was sent and an appointment offered to discuss with the patient the risks, and how these could be mitigated. The practice provided evidence that all patients had been contacted and were supported in making an informed decision regarding this medication.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation and we reviewed effective processes of sharing this information within the practice. Clinical records we saw demonstrated care was provided in line with current guidance, documentation was precise, consultations were audited by clinicians where appropriate. Staff carried out audits of non-medical prescribers and noted no issues in this area, this group of staff were provided regular peer support.

The practice had a clear and comprehensive process which attempted to reach patients who did not attend for cervical smears and adjusted provide appointments which would suit this patient group. They had also utilised the social prescriber in attempting to reach this cohort of patients. At the time of our site visit the practice had achieved targets for cervical smears, however, were still aiming to contact patients who did not want to come into the surgery.

Clinical searches carried out as part of our inspection demonstrated a comprehensive recall system. Medication reviews were conducted mainly by the pharmacist within the practice, for patients of a complex nature this was done by a clinician. All patients we noted as ‘overdue’ for review had been contacted by the practice, and documentation clearly outlined reasons why this group of patients may not have attended. There was again, a comprehensive process in place for staff to follow in relation to medication being prescribed to patients if a review was overdue, this is communicated with the patient via text message.

The provider demonstrated numerous audits that had been carried out following the two-cycle method that had a positive impact on patients. The practice had implemented an audit looking at patients who may require a medication to protect their bones. This is calculated using a Fracture Risk Assessment Tool (FRAX). Certain medications are known to increase this risk. The practice audited patients who had been on these medications for longer than three months. The audit highlighted 47% of eligible patients had an accurate FRAX score. A protocol was put in place, and when data was re-collected three months later 100% had the correct scores in place. There is now an embedded process which will ensure patients who are within this risk category receive appropriate assessment when required.

Furthermore, the provider demonstrated willingness to share this work with practices nationally to improve outcomes for as many patients as possible.

The practice had recognised a difficulty in coding patients with chronic kidney disease who did not fall into a set characteristic resulting in clinicians constructing an audit based on ensuring these patients could be coded. There was a two-cycle audit carried out which demonstrated an improvement on coding, a new protocol was implemented and shared with all clinical staff. The practice has continued to review data from this audit and have constructed a new aim of a 90% achievement rate which will be revisited in 2026.

Furthermore we reviewed evidence of improved patient outcomes following the introduction of a quality improvement project which targeted a patient group who were at risk of a cardiovascular event. The practice completed an assessment and targeted this group, through both medication and health promotion advice at regular intervals. The project included 1412 patients, and we reviewed results which demonstrated 42.8% of these patients had improved High-Density Lipoprotein Cholesterol (HDL-c). These patients all aligned within the suggested guidance from National Institute for Clinical Excellence (NICE). With intervention from the practice, the 42.8% of patients reduced their non-HDL-c, by 18%.

The service always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. This had been enhanced with the introduction of the continuity of care approach. Staff had received training on sharing information with the named GP and there was a clear process in place for ensuring any information from other services was reviewed by this clinician. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. The practice held a weekly Multi-Disciplinary Team meeting where services would discuss vulnerable patients, share examples of good practice and provide support to one another if it was required. The practice is aligned with two local care homes, we spoke to the staff at the homes who told us they felt the practice, especially the named GP, worked with them to deliver excellent care to their residents. They were able to get an appointment when required, emergency health care plans and DNCPR’s were kept up to date. Care home staff had also been provided an alternative telephone number to contact the practice at busy times. The practice utilised the patient participation group (PPG), the PPG told us when issues or suggestions were brought to the practice they were listened to and resolved promptly. For example a suggestion had been put forward regarding a further disabled parking space within the car park, the practice immediately sought to resolve this.

The service always supported people to manage their health and wellbeing to fully 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 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. Staff took opportunities to speak to patients regarding health promotion at the time of consultation. Where required patients could request a longer appointment. All staff within the practice utilised care navigation or social prescribing.

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

The practice met national targets, for cervical smears, women under 49 the practice had achieved 85% with a target of 80%. For women over 50, the practice had achieved 92% with again a target of 80%. Furthermore, childhood immunisations were all achieving target at the time of our site visit.

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. Clinicians were enthusiastic about quality improvement and strived to ensure all patients received the best outcomes. We reviewed audits which clearly demonstrated improvement for patients. The leadership had considered the needs of the local population and community, and where there were risks, for example the area of Wallsend was historically industrial, therefore there was a higher demographic of patients who were potentially at risk of developing industrial diseases. The practice had developed innovative screening processes for those at risk of lung cancer and we saw evidence of positive outcomes for patients because of being treated earlier than they would normally have been. Due to the work carried out by the practice and others, there is now a nationally recognised Lung Cancer screening programme in place.

Stakeholders told us that clinical staff within the practice were open to improving and trialling new ways of working, and we saw this clearly demonstrated at the time of our site visit. Management ensured that changes to processes were clearly communicated with staff to ensure patient care was not disrupted. We saw evidence of the introduction of continuity of care being introduced periodically to minimise disruption with the most vulnerable patients being allocated first. This implementation was reviewed regularly and amended where necessary. The practice undertook an audit of non-medical prescribers (NMP) which looked at the prescribing of antibiotics and controlled drugs. The audit involved spot checking 10 randomised prescriptions from each NMP. There were no concerns following this audit, with no themes identified or areas of concern.

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. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. We saw evidence that consent was being recorded where required. Staff had an understanding of power of attorney and documented these arrangements appropriately.