Somerford Grove Practice

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• 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 practice made sure people's care and treatment was effective by assessing and reviewing their health, care, well-being and communication needs with them. Patients with long-term conditions were actively recalled for review and clinicians used structured templates to support assessment and care planning. The practice identified and monitored patients at risk of developing long-term conditions and worked with multidisciplinary teams to support ongoing management.

Feedback from people using the practice was positive. People felt involved in assessments of their needs and felt confident that staff understood their individual and cultural needs. 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 well-being 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 service planned and delivered people’s care and treatment with them, including what was important and mattered to them. Staff accessed regular educational sessions and clinical discussions to support professional development and maintain knowledge. The practice had also developed an innovative integrated diabetes review template that supported consistent and structured annual reviews and improved patient engagement in managing their condition.

The practice worked well across teams and services to support people. Staff worked closely with multidisciplinary teams including pharmacists, paramedics, mental health practitioners, health visitors, midwives and specialist nurses. Monthly meetings with partner organisations supported continuity of care and information sharing. Daily clinical meetings enabled discussion of patients with complex needs and promoted coordinated working across the practice.

The practice supported people to manage their health and well-being and promoted healthier lifestyles. Smoking cessation and weight management referrals were available. Patients could access social prescribing services, well-being support and community-based initiatives. The practice worked with volunteer groups and community projects to promote health and well-being and reduce social isolation. Staff also identified and supported patients who may benefit from additional preventive interventions.

Staff focused 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.

GP Patient Survey results showed that 82% of respondents felt they had received enough support from local services or organisations during the previous 12 months to help manage their long-term conditions or illnesses, compared to 63% locally and 70% nationally.

The service had systems to monitor care and treatment and described processes to improve uptake of cervical screening and childhood immunisations. Staff used recall systems, opportunistic screening and electronic alerts to identify patients requiring screening or vaccination, and non‑responders were followed up.

Published cervical screening data available at the time of assessment showed uptake below the national target for the relevant cohorts. Published childhood immunisation data for the same period also showed uptake below the World Health Organization target across several vaccination programmes.

The provider supplied more recent local dashboard data for both cervical screening and childhood immunisations. As this information had not been independently validated through national reporting systems, it could not reliably demonstrate the extent of improvement.

Staff nevertheless described ongoing work to improve uptake, including reviewing non‑responders, using clinical searches to identify outstanding vaccinations and screening, and adapting their approach based on emerging risks and population needs. These activities indicated effort to improve outcomes, although published data continued to show performance below national targets.

The practice told people about their rights around consent and respected these when delivering care and treatment. Staff understood and applied relevant legislation, including the Mental Capacity Act 2005. Capacity assessments, consent discussions and DNACPR decisions were recorded using structured templates. We reviewed three DNACPR decisions. All three were completed in full using the structured template, with clear documentation of capacity, consent discussions and clinical rationale.

The practice used end-of-life care planning templates to support shared decision-making and documentation of patient wishes.

GP Patient Survey results demonstrated that patients were involved in decisions about their care and treatment. Of respondents, 94% said they were involved as much as they wanted to be in decisions about their care and treatment during their last appointment, compared to 89% locally and 92% nationally.