Southfields Group Practice

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 patients in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed patients 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, however there were some areas that the practice needed to improve.
Patients were involved in assessments of their needs. Staff reviewed assessments taking account of patients’ communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in patients’ care for the best outcomes and smooth transitions when moving services. Staff made sure patients understood their care and treatment to enable them to give informed consent. Where patients didn’t have capacity, and staff took decisions about the patient’s care in their best interest, they involved those people who were important to the patient in the decision.
 

This service scored 71 (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 made sure patients’ care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.
Feedback from patients using the service was positive. Data from the national GP patient survey showed patients felt involved in assessments of their needs, with 97% of patients saying they were involved as much as they want to be in decisions about their care and treatment during their last GP appointment local 92% national 91%.
Patients 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 patients’ health, care, and wellbeing needs during health reviews.
Clinical staff used templates when conducting care reviews to support the review of patients’ wider health and wellbeing. The provider had effective systems to identify patients with previously undiagnosed conditions. Staff could refer patients with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.
 

In most cases the practice planned and delivered patients’ care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.
Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Most clinical records we saw demonstrated care was provided in line with current guidance.
In most cases our clinical searches confirmed that the practice carried out comprehensive medication reviews. In general GPs demonstrated oversight of patients’ prescribed medicines that required regular monitoring; however, we did identify areas that needed improving. For example, 1 search identified out of 5 records checked 2 patients were overdue an asthma review, the risk to patients was minor.
Another search we looked at a sample of 5 records and found 2 out of 5 patients sampled with a raised HbA1c (a measurement of sugar in your blood) needed following up.
When we raised this with the practice they said they would follow up those patients identified and that patients were sent invites and reminders to attend reviews.
Another clinical search identified 15 patients as having potential missed diagnosis of chronic kidney disease. We reviewed 5 records and found 3 patients had not been informed of the diagnosis and had not had appropriate follow ups or investigations done, the level of risk was minor.
We reviewed the records of 5 patients on a medicine used to strengthen bones and reduce fracture risk. We found all 5 patients were not being monitored and reviewed as required, this potentially was a major risk as patients could sustain bone fractures due to inadequate monitoring.
 

The service worked well across teams and services to support patients. They made sure patients only needed to tell their story once by sharing their assessment of needs when patients moved between different services.
Staff had access to the information they needed to appropriately assess, plan, and deliver patients’ care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.
Nurses told us GPs had weekly meetings they could attend. Staff told us leaders and partners were approachable, and the practice had an open-door policy. The practice manager also told us they worked closely with local practices within the primary care network.
 

The service supported patients to manage their health and wellbeing to maximise their independence, choice and control. The service supported patients 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.
Data from the 2025 National GP patient survey showed that 77% of patients completing the survey felt they received enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses. This was higher than the local average of 70% and the national average of69%. The survey showed 87% of patients said the healthcare professional they saw or spoke to was good at considering their mental wellbeing during their last general practice appointment. This was higher than the local average of 76% and national average of 74%.
 

The service routinely monitored patients’ 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 patients themselves.
The practice did not meet all national targets for screening and immunisations. Out of 5 childhood immunisation targets, they met 4. The practice was slightly below national targets for screening up take, the practice was aware and actively monitored and recalled patients. From the clinical notes we reviewed, we found that patients who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.
The national GP patient survey data collected between December 2024, and April 2025 showed that 98% of respondents felt they had all the information they needed (local average was 93% and the national average was 92%).
The practice manager informed us as well as following up patients for cervical screening she also ran searches and followed up patients who had just turned 71 to inform them they are still able to have screening done.
 

The service told patients about their rights around consent and respected these when delivering person-centred care and treatment.
Only clinical staff had completed mental capacity and deprivation of liberties training.
Staff understood and applied legislation relating to consent. The GP told us that if there was doubt as to someone’s capacity, this was recorded. Consent and capacity were documented in patient records appropriately. We saw evidence that staff and family members were included in decisions about care. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.
We reviewed 3 (DNACPR) records and found decisions were appropriate and were made in line with relevant legislation, however we identified that care plans were not always visible and only a blank form could be seen. The practice said they would raise this with the IT supplier and perform an audit on all DNACPR records to ensure forms were attached and visible.