Stephenson Park Health Group

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. However, monitoring of long-term conditions required some improvement.

At our last assessment, we rated this key question as outstanding. At this assessment, the rating has changed to good.

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.

Feedback from people using the service was positive. People felt involved in any assessment of their needs. The 2024 GP Patient Survey showed that 94% of patients felt involved as much as they wanted to be in decisions about their care and treatment.

The Learning Disabilities (LD) Coordinator had attended 4 workshops or group meetings over the past 12 months, supporting ongoing engagement and continuous improvement in care for individuals with learning disabilities.

The Carers Champion confirmed their active involvement in Carers Network Meetings, Adult Carer Meetings, and Child Carer Meetings, and also organised a Carers Coffee Morning in October 2023. They proactively contacted local schools to identify and support any young carers and maintain regular contact with the Carers Centre for North Tyneside, ensuring that information about upcoming training and events for both adult and child carers was shared and displayed.

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. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The practice was a veteran-registered practice, demonstrating its commitment to identifying and supporting the specific health and wellbeing needs of veterans.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them.

The practice provided a range of specialist clinics on-site, including Cryotherapy, Minor Operations, Coil Fittings, Musculoskeletal (MSK) services, and Ear Irrigation. By offering these services within the practice, patients benefited from improved accessibility and reduced need for hospital referrals, enhancing both convenience and continuity of care.

The practice also participated in the NHS North East and North Cumbria (NENC) Integrated Care Board and Health Innovation remote monitoring pilot programme. As part of this initiative, new remote monitoring pathways were tested for routine condition management—such as contraceptive pill checks, HRT reviews, asthma, and paediatric skin conditions. The aim was to explore innovative ways of increasing capacity while improving patient care and experience.

The practice provided 3 clinical audits as part of their quality improvement efforts: a single-cycle audit on the prescribing of oestrogen-only HRT, and 2-cycle audits on post-partum blood glucose monitoring and warfarin management.

The HRT audit assessed whether women on oestrogen-only HRT without a hysterectomy were receiving appropriate endometrial protection. A small number of patients were found not to be receiving appropriate protection, and actions were taken to address these cases. The practice told us they intend to repeat the audit every 6 months.

The post-partum glucose audit was a 2-cycle audit, which identified a 70% compliance rate with the recommended blood glucose testing in women diagnosed with gestational diabetes. Following reminder interventions, compliance improved to 78%.

The warfarin audit was a 2-cycle audit aimed at identifying patients with a Therapeutic Time in Range (TTR) below 65% and ensuring safe and appropriate management. Of 77 patients, 34 had suboptimal TTRs. A follow-up audit showed that 43% of these patients had improved TTRs, with some reaching target levels. Where consistently low TTRs were identified, patients were flagged for GP review. The practice told us they planned to continue monthly monitoring and re-auditing to support patient safety.

The practice hosted several training events throughout the year to support ongoing professional development. Clinicians participated in dedicated events, focusing on targeted learning for staff. Additionally, learning from Significant Event Analysis (SEA) was shared to enhance clinical practice and promote continuous improvement.

However, a review identified gaps in some areas of clinical oversight and safety monitoring, particularly in the management of long-term conditions and high-risk medications.

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.

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.

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.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, such as supporting people with mental health needs, delivering NHS Health Checks, signposting to weight management and referring into social prescribing and wellbeing support.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Results from our clinical searches indicated that improvements were needed in the monitoring of patients with certain long-term conditions and the process for acting on legacy safety alerts.

The latest verified data held from 2023 showed the percentage of persons eligible for cervical cancer screening who were screened adequately was 72.2% compared to expected uptake of 80%. However, the practice provided a summary of their Quality and Outcomes Framework (QOF) data, which covered the period up to March 2025. Although this data had not been verified, it showed higher cervical screening rates, with 87.3% of individuals aged 50-64 and 89.1% of individuals aged 25-49 receiving appropriate screening.

Our monitoring showed that the practice was meeting the national target of 90% for childhood vaccinations.

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.