The Ridgeway 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 remains the same.
 

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 people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. Patients with long-term conditions, learning disabilities, mental health needs, frailty, safeguarding concerns, carers, and those who were housebound were identified through clinical coding, routine reviews, and multidisciplinary discussions. Housebound patients were maintained on a separate register to ensure timely monitoring, medication reviews, and appropriate follow-up care. Staff were aware of patients’ individual support and communication needs through coded alerts and care notes within the clinical system. This was to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present.

Patients could be referred to Social Prescribers for support with social, emotional, financial, or wellbeing concerns, as well as to specialist services such as Diabetic Specialist Nurses, community nursing teams, mental health services, safeguarding teams, and other allied healthcare professionals.
 

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. The clinical records we reviewed demonstrated that care was provided in line with current guidance. For example, a sample of 5 patient records were looked at for medication reviews, and these were found to be comprehensive.

The practice had an Evidence-Based Practice and Clinical Education Policy which was to ensure that clinicians at the practice remained up to date with current evidence-based practice, national guidance, local clinical pathways, and professional standards.

Over the past two years, a structured programme of clinical audits had been undertaken by the practice as part of ongoing quality improvement activity. This included a Clinical Decision-Making and Pathology Management Audit. This assessed compliance with agreed access and safety protocols. This also included a re-audit into Bisphosphonate prescribing which reviewed against national guidance to ensure appropriate initiation, duration, and review of long-term therapy. The original audit identified deficiencies in osteoporosis management and the re-audit aimed to assess whether improvements introduced during the initial audit had been maintained and whether compliance with NICE and National Osteoporosis Guideline Group (NOGG) guidance had improved further during 2025–2026. The re-audit demonstrated significant improvement compared with baseline data from 2024.

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. The practice worked collaboratively with colleagues across Healthsense Primary Care Network (PCN), community services, mental health teams, social care and voluntary sector organisations to provide coordinated, patient-centred care. The practice worked with other services to ensure continuity of care.

The practice worked closely with the Healthsense PCN Health Social Wellbeing Team, which included Social Prescribers, Care Coordinators and Health Wellbeing Coaches. These roles supported patients with practical, emotional and social factors affecting health and wellbeing. Examples of support included: support for loneliness and social isolation, food bank and food voucher signposting and carers’ support. The practice was also a local food bank voucher referral site and supported vulnerable patients by issuing food bank vouchers where appropriate.
 

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.

The practice actively support a wide range of national NHS priorities and local health initiatives. The practice had a focus on prevention and actively promoted service aimed at improving patient health. This included NHS Health Checks, national vaccination and immunisation programmes, cancer screening programmes, smoking cessation support and referrals, alcohol reduction and substance misuse interventions, sexual health and contraception services, weight management support and cardiovascular disease prevention initiatives.
 

The service regularly monitored people’s care and treatment to continuously improve it. The Office for Health Improvement and Disparities data from June 2024 showed that the percentage of persons eligible for cervical cancer screening who were screened adequately within 3.5 years for persons aged 25 to 49 was 60% which was below the 80% national target. The number of women aged 50 to 64 years old who had had an adequate screening test within the last 5.5 years as a percentage of the eligible population, was 70% which was below the 80% target.

The percentage of children aged 5 who had received immunisation for measles, mumps and rubella (two doses of MMR) was 84% in comparison to the WHO (World Health Organisation) target of 95%. The percentage of children aged 2 in this category was 86% which was below the target of 95%.The practice recognised this and have taken action to try and increase uptake which included offering Saturday clinics for the PCN. A nurse was contracted for these sessions.

The practice carried out a Cervical Screening Non-Attendance Survey to also better understanding why some patients chose not to book a cervical screening appointment despite invitation. Practice found that the most common theme related to appointment access and booking arrangements. The survey demonstrated that non-attendance was driven by a mixture of practical, personal and clinical factors. The survey findings were used to inform ongoing improvements to the practice's cervical screening programme, including continuing to offer a range of appointment times, reviewing invitation and recall processes to reduce inappropriate reminders and providing additional reassurance and information for patients who are anxious about screening.
 

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. All staff we spoke with during the assessment understood and applied legislation relating to consent. We saw evidence that Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.