Jorvik Gillygate 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 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.

Jorvik Gillygate Practice made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing, and communication needs with them.

Feedback from people using the practice was mostly positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs.

Staff were aware of the needs of the local community and used digital flags within the care records system to highlight any specific individual needs. 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 practice also had effective systems in place 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 and an example of this working well was provided by the practice.

This example related to a patient who had a pest infestation in his home. Following referral to social prescribing support, a coordinated response was arranged involving environmental health and local charities. This ensured the property was professionally fumigated, contaminated items were safely disposed of, and replacement clothing and essential household items were provided.

As a result, the patient’s living environment was made safe and hygienic, supporting improvements in both their physical health and mental wellbeing.

Jorvik Gillygate Practice 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 National GP Patient Survey results showed that 91% of patients felt that the healthcare professional they saw had all the information they needed about them during their last GP appointment. Although this was slightly below the local and national averages of 92%, the difference was minimal.

The practice was actively promoting Jess’s Rule on noticeboards in clinical rooms and reception. This is a primary healthcare initiative to encourage GP teams to rethink a diagnosis if a patient presents three times with the same symptoms or concerns, particularly if symptoms unexpectedly persist, escalate, or remain unexplained. It is led by the Department of Health and Social Care and NHS England and is supported by the Royal College of General Practitioners.

Jorvik Gillygate Practice worked well across teams and services to support people. It made sure patients only needed to tell their story once by sharing thorough assessments of people’s 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 and staff were working with their local primary care network (PCN) to meet the needs of the patient population and for example, over the previous 12 months the practice had undertaken work with York City PCN to improve identification and follow-up of non-responders to breast, bowel and cervical screening.

This work had involved a PCN-wide audit of cancer diagnoses and screening patterns to identify where patients first presented and whether learning could improve early detection. It also involved joint discussion across the practices on shared barriers, variation, and processes for patients with learning disabilities or those living in care homes.

As a result of this work Jorvik Gillygate Practice had introduced a standardised third invite for cervical screening and also implemented text reminders for breast and bowel screening non-responders, including signposting to national helplines and programme contacts.

These measures had led to more consistent and equitable follow-up of non-responders; an improved understanding of reasons for non-response to inform future interventions; and enhanced early detection focus in the practice and across the PCN.

Jorvik Gillygate Practice supported people to manage their health and wellbeing to maximise their independence, choice, and control. They also 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 such as stopping smoking and tackling obesity.

Our clinical searches showed that 290 patients had had a medication review within the past three months. Five of these were looked at in more detail and overall, the quality of the reviews was good.

Jorvik Gillygate Practice had systems in place to monitor patient outcomes; however, we found that these were not always applied consistently to drive continuous improvement.

For example: performance data indicated that the practice was under the 80% national target for screening of cervical cancer in 25 to 49-year-old women (71.2%) and for women in the 50 to 64-year-old age group (75.5%).

Performance data also indicated that, although the practice met the 90% minimum target for 3 childhood immunisations, they were slightly under target for 2 others – specifically, children aged 5 who had received immunisation for measles, mumps and rubella (two doses of MMR) and children aged 2 who had received their booster immunisation for pneumococcal infection (PCV booster).

The practice were aware that they were not meeting national targets in these areas and we saw during our assessment that they were trying to address this by promoting childhood immunisations and the national cervical screening programme in the practices as well as promoting annual health checks.

In addition to the above, as part of our series of patient clinical record searches, we identified issues with the monitoring of some long-term conditions and certain medications. Specifically:

• 157 patients were identified with diabetes who’s latest HbA1c (blood test to check blood sugar levels) was more than 75mmol and when 5 of these were looked at in more detail, 4 were overdue an annual review:
• 267 patients were identified as having a potential missed diagnosis of chronic kidney disease (CKD) stage 3, 4 or 5 and when 5 of these were looked at in more detail, 3 had a missed diagnosis of CKD and 1 required repeat urea and electrolyte testing: and
• A small number of patients with hypothyroidism (12 out of 841) were identified who appeared to be overdue thyroid function tests and/medication reviews. Of these, 5 were reviewed and, 3 had overdue blood monitoring, and 3 had an overdue medication review.

As a result of the findings, the practice was asked to review the patients that we had identified. They immediately did this and either provided mitigation as to why monitoring had not been done or implemented actions to address the issues.

On a positive note, our clinical record searches found that the monitoring of patients with CKD stages 4 or 5 was generally good and that patients prescribed gabapentinoid medication (medication primarily used to treat conditions like neuropathic pain and seizures) were receiving the appropriate monitoring.

Patients with a learning disability were offered an annual health check and local monitoring arrangements for ensuring the checks were offered were in place. Unverified data provided by the practice showed that there were 75 patients registered on their Learning Disability Register and that, as at March 2026, 73 had been contacted and 48 had received an annual heath check in the previous 12 months.

In addition, NHS health checks were offered to patients as part of locally agreed contracts. Unverified data provided by the practice showed that in the last 12 months 130 patients had been invited for an NHS health check, and 123 checks had been completed.

Jorvik Gillygate Practice told people about their rights around consent and respected these when delivering person-centred care and treatment.

It had a consent policy in place which included clear information for staff about the different forms of consent a patient may give and how a patient may withdraw it at any time. The policy also included a section on consent for children and young people alongside a formal consent form for patients to complete when having specific procedures, such as minor surgery.

Staff we spoke with knew to consider whether a child under 16 may consent to their own medical treatment without parental knowledge or permission. This ensured that young adults had control over their own privacy and the amount of parental involvement in managing their care and support.

Recent audits of patients who had received covid and flu vaccinations, cervical smears and childhood immunisations found 100% compliance with obtaining consent prior to vaccination and we saw during our visit that capacity and consent were both appropriately recorded on patient records.

Mental Capacity Act training was mandatory for all staff and everyone had completed it.

Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. Where individuals lacked the capacity to make decisions, staff engaged those who were important to them to act in their best interests.