St Mary’s 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 with 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 service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. We carried out a series of searches on the clinical systems as part of this assessment that showed a process for the effective management of patients with long-term condition, such as diabetes.

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 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.

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 results of the 2026 National GP Patient Survey were higher than national average. For example, 100% felt the healthcare professional they saw had all the information they needed about them, compared to 92% nationally and 93% locally, and 97% felt their needs were met during their last general practice appointment, compared to 90% nationally and 91% locally.
 

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

The 2026 National GP Patient Survey showed that 99% of respondents (compared to 93% nationally and locally) stated that during their last appointment they had confidence and trust in the healthcare professional they saw or spoke to.
 

The service worked well across teams and services to support people. Leaders and staff we spoke with described how continuity of care was a priority within the practice, and it was important for patients to have contact with the same GP. 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.

Leaders we spoke with told us how they use their Integrated Community Care team (ICC) to form links in the community and described how the practice reaches out to work with community groups, social prescribing and help with carers.

The service used meetings and practice learning time to discuss clinical review findings with all staff, and this was evidenced in documents we viewed. Leaders also evidenced how the service conducted regular palliative care framework meetings with district nurses to discuss palliative care and end of life care reviews.
 

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. Leaders we spoke with described integrated care work with promoting people to live independently in their own homes and how they use their ICC team to perform holistic care reports in people’s own homes to help maximise independence.

Leaders evidenced ongoing work within local community to tackle health inequalities, including weekly health checks and blood pressure tests at livestock marts to reach out to the local rural farming community and work within the hospitality sector to tackle poor health within the migrant worker population. The emphasis amongst both community groups was to promote attendance at the practice for regular health checks and promote the importance of screening and immunisations.

Leaders described a pilot scheme being used within the practice and primary care network to support autistic people and people with a learning disability who may find conventional venous blood tests distressing. The practice had introduced capillary blood testing as part of routine health monitoring. Leaders told us the pilot had been well received, with positive and effective outcomes for people using the service, and they were hopeful the approach would be rolled out more widely in the future.

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 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 utilised discreet sexual health screening self-testing kits within the service along with box to post kits for testing and displayed sexual health clinic information.

The most recent published data as of 30 June 2024 shows the practice achieved cervical screening uptake of 73% among patients aged 25 to 49 years and 78.1% among those aged 50 to 64 years, compared to national target of 80%, and childhood immunisations for 1- and 2-year-olds shows 100% uptake, compared to national 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 service had established systems to monitor non-attendance for both immunisation and screening appointments.
 

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. Staff received mental capacity training that was up to date. Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded.

A review of clinical records for do not attempt cardiopulmonary resuscitation (DNACPR) decisions showed that appropriate decisions were in place and coded in a way that could identify patients. DNACPR decisions were appropriate and were made in line with relevant legislation.

The 2026 National GP Patient Survey results indicated that 96% of respondents had stated that during their last appointment they were involved as much as they wanted to be in decisions about their care and treatment, compared to 92% nationally and locally. Staff we spoke with understood the importance of ensuring that people fully understood what they were consenting to and the importance of obtaining consent before they delivered care or treatment. There was a system in place to record people’s consent appropriately.