Stillington 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. The provider collaborated effectively with the local community hospital to improve outcomes for patients. There was effective communication and effective clinical input from the practice. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity.

This service scored 83 (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. For example, our clinical searches identified zero patients with a potential missed diagnosis of diabetes or chronic kidney disease. Oversight and monitoring of patients with long term conditions and potential missed diagnosis was exceptional.

Patients requiring medication reviews and monitoring for certain long-term conditions such as asthma, hypothyroidism, and diabetes had had these carried out effectively and appropriately.

The service collaborated effectively with the local community hospital, leading the delivery of clinical care for its own patients there. The practice ensured health, care and wellbeing was supported and was able to ensure its patients could receive palliative and short-term medical care closer to home without travelling to the city of York.

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. Reception staff were well aware of the needs of the local community.

The practice was in the initial stages of using 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. Due to the small size of the practice patient list, staff knew their patients well and constantly made reasonable adjustments to meet their needs, for example, ringing patients with dementia on the day of their appointment to remind them.

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.

The practice’s clinical coding system had been regularly cleansed, and correct coding was frequently applied to records. The use of advanced technology already in place, and an upcoming artificial intelligence system supported clinical coding, recalls and reminders to patients to attend for reviews of their condition or medication.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance. Searches on the practice’s clinical system showed that all patients on blood thinning medications had received the required monitoring. Patients who required medications used to treat autoimmune diseaseshad been appropriately monitored in the clinical searches that we conducted.

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 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.

We saw evidence that the practice had regular meetings which were used to share any changes across the practice. However, some staff members believed that communication could be improved further.

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 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 PPG had done a significant amount of work in furnishing the waiting room with a plethora of health promotion material in leaflet, poster and digital formats, through the use of a TV screen. As part of their Primary Care Network (PCN) the practice could refer patients to a social prescriber.

The practice helped to run an annual Community Health Day for its patients, providing information and support to help them lead healthier lives. It was an open event that brought together a wide range of organisations, such as cancer care charities, carer support groups, cardiovascular health charities, social prescribing teams, local volunteer groups, and men’s mental health support organisations, all offering information and guidance throughout the day. Nurses from the practice provided complimentary blood pressure and pulse checks and were available for discussions with attendees.During this year’s upcoming event, the practice plans to expand the programme to include sessions tailored to specific groups, including farmers, military veterans, and adolescents, alongside several other health focused topics. The event is advertised through the practice itself, the Patient Participation Group, local village newsletters, and local schools.

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.

The practice met national targets for screening and immunisations. The national target for routine childhood vaccinations is 90%. The World Health Organisation (WHO) recommends a rate of 95% for all routine childhood vaccinations. The most recent data (2023/24) showed the practice had achieved 90% in 4 out of 5 routine childhood vaccination age groups and slightly below 90% in 1 out of 5 areas. Where this figure was slightly below expectation, the practice provided well documented evidence of their efforts to meet this target, and the removal of barriers for hard-to-reach patients. The national target for cervical screening coverage is 80%. The most recent data (2024) showed that practice had achieved 82% for eligible patients aged 25 – 49 years old. They achieved 86% for eligible patients aged 50 – 64 years old.

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.

Coding for patients with respect forms was effective. Clinicians sought informed consent from patients receiving joint injections. One of the partners had published journal articles regarding the topic of consent.