Stonecot 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

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 has improved.

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.
95% of those who responded to the 2025 National GP Patient Survey said that the healthcare professional they saw or spoke to was good at listening to them during their last general practice appointment (compared to a national average of 87%).
95% of those who responded to the 2025 survey said that they were involved as much as they wanted to be in decisions about their care and treatment during their last appointment (compared to a national average of 91%).
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 could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.
The provider had systems to identify people with previously undiagnosed conditions. We saw this was the case in the records we reviewed. The service carried out quarterly audits to make sure that diagnoses were not missed. We looked at 3 audits which showed improvement as learning was identified and shared.
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 service had a relatively large population of older people and 12% of all the practice patients were living with frailty. Frailty is a state of ageing in which multiple body systems gradually lose their in-built reserves. Older people living with frailty are vulnerable to dramatic deteriorations in their physical and mental wellbeing after what would otherwise be a minor health event, such as an infection or new medicine.
The service had worked to improve care for this group of patients but recognised that there was more to do to reduce hospitals admissions and improve quality of life. 4749 patients in the primary care network were deemed to be either moderately or severely frail. Of this 1407 of these people (30%) were registered with Stonecot Surgery.
Service leaders worked with other practices in the primary care network, Age UK Merton, the local hospital and community healthcare provider to develop a project and made a successful bid for innovation funding for a pilot that brought together professionals from the GP practice, the local hospital, the community health provider and Age UK Living Well practitioners to better co-ordinate and document care for people identified by national criteria for frailty and who were housebound.
289 individual patients were discussed in multi-disciplinary meetings, of which 112 were patients of Stonecot Surgery (39% of all patients in the pilot). Data provided by the Integrated care Board showed that patients from Stonecot Surgery who had received this more intensive proactive care required 25% less unplanned care in the 3 months afterwards than in the previous 3 months. Data also showed that if these people did need to be admitted to hospital, they had a shorter stay (by 10%).
One of the service leaders presented the findings, with the other primary care network clinical director, to other practices in the GP Federation, to the Integrated Care Board and nationally to NHS England at the Community of Practice event in July 2024. Following the project’s success, the borough adopted a whole-system approach to managing frailty.
The service felt the benefits were great enough to continue with the approach, including multi-disciplinary meetings and home visits, after the funding ended.

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. They worked to develop evidence-based good practice and standards.
Systems in place to ensure staff were up to date with evidence-based guidance and legislation were effective and this translated into the care people received. Clinical records we saw demonstrated care was provided in line with current guidance.
When clinical guidance changed, the service took a coordinated approach to ensuring care improved. For example, in 2023 the guidelines for Chronic Kidney Disease management were updated. The service’s response included education and supervision of clinical staff to support evidence-based prescribing, targeted training so staff could confidently explain to people why tests were required, searches of the patient information system to identify people with heart failure and high blood pressure who might have undiagnosed CKD, and regular ongoing missed-diagnosis audits for CKD and diabetes to ensure patients were appropriately diagnosed, coded and treated in line with current standards.
The service found improvements in all the areas targeted. For example, by 2025 the percentage of people with CKD who had the necessary blood tests increased from 88% to 95%. We saw data that showed the improvement had been sustained in 2026 and the service had plans to make further improvements.

The service presented their processes and data at a national diabetes conference in 2025.

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. Staff were supported by software that made it easier and more efficient to ensure that people received the care recommended.
In July 2025, the practice rolled out an automated process to follow up people overdue for monitoring of their long-term condition. The service created bespoke templates that reflected the monitoring needed for different long-term conditions, such as specific blood tests, review appointments, or blood pressure checks. Every Wednesday the software checked against the templates and identified 40 people with the most overdue monitoring. The system automatically sent these people a text message, with a link to allow them to book an appointment at a convenient time.
In July 2025 approximately 4.5% of people were overdue ‘a task’ such as a blood test or weight check. This reduced to approximately 2.5% in February 2026 after the introduction of the automated system.
The percentage of appointments booked to manage long-term conditions decreased between 2023/2024 and 2025/2026.
Since the number of people overdue for monitoring also decreased, this indicates that so many long-term condition specific appointments weren’t needed because routine monitoring had improved.
The service sought opportunities to work in innovative ways with other services to improve the quality and continuity of care. The service was part of a pilot community outreach model working with consultants from a local hospital. The approach included identifying patients at higher risk, collating contextual information to support decision-making, and working with consultants and patients on making and implementing management plans.

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.
The service had assessed the health and wellbeing needs of people registered with the service and developed its own initiatives and engaged with national and local schemes to support people specifically with these.
The service had identified that people registered with the service were at higher risk of vascular health conditions. These effect the blood vessels and the heart, and include high blood pressure, chronic kidney disease and diabetes.
The service trained the clinical pharmacists, physician assistant and prescription clerks in the clinical management of the risk factors for vascular conditions including control of blood pressure, blood fats and blood sugar, and how to assess urine samples to detect early kidney damage caused by diabetes or high blood pressure. A health care assistant and phlebotomist were recruited and trained.
To improve further, and to ensure that the efforts resulted in measurable improvements in health outcomes, the service combined with the other local practices to join a national initiative focused on helping primary care networks improve cardiovascular disease prevention.
The service worked on modelling with a team of NHS clinicians and data scientists. It was predicted that the project could prevent up to 2 heart attacks and 3 strokes and reduce the number of people developing diabetes by 20% – improving people’s overall health.
The focus was on holistic care and preventing further ill-health rather than managing individual medical conditions, with fewer appointments that people need to attend, and creation of individualised holistic health and lifestyle plans, with targets monitored and supported by a dedicated team.
We saw documents that showed the work that the service had already completed prior to joining the national initiative formed the basis for the approach locally, and that leaders from the service worked with an external advice team on how to adapt the service workflow for adoption across the primary care network. An email from a senior clinical consultant from the national team expressed gratitude to Stonecot Surgery leaders, described the approach adopted by the service as “gold standard” in terms of benefits to people’s health and efficient delivery of care, and confirmed that the service is ahead of others in their innovation and implementation.

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 service monitored people’s care and treatment in a range of ways, including software that worked with the information system. The service used formal audit to monitor improvement work, and especially improvement for the most vulnerable people.
For example, the service had targeted and audited end of life care. Between 2023 and 2026, the percentage of people who died in their preferred place increased from 39% to 95% (and analysis showed the remainder had not died in their preferred place for clinical reasons rather than lack of planning). In the recent data, 98% of people had a Universal Care Plan and were also referred to a specialist end of life service.
In common with most GP practices in London, the service had not met all of the national targets for screening and immunisations, but had action plans in place to improve take up. The practice showed us data that demonstrated improvement, but this could not be compared to the national, verified data.
For example, in the most recent verified data the service met the uptake target for cervical screening in women aged 50+ but was not meeting the 80% target for women aged 25 – 49 (70.8% uptake).
To improve this, the service set up automated calls and text messages with people due for cervical screening. We saw data that showed that after this had been launched in June 2025, uptake was better in every month compared to the same month in 2024 – and increased by 7% overall.
Although the data cannot be compared to the nationally verified data, data from the service showed an uptake of 79% for the 25 – 49 age group.
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 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.