Holmside Medical 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.

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

This service scored 88 (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 always made sure people’s care and treatment was effective by thoroughly 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 and felt confident that staff understood their individual and cultural needs.

There was a holistic approach to assessing planning and delivering care and treatment to people who used services. There was a safe use of innovative and pioneering approaches to care and how it was delivered and actively encouraged. New evidence-based techniques and technologies were used to support the delivery of high-quality care.

The practice were pioneers in using the NHS-supported approach, year of care, to managing long-term conditions (LTC), for example for diabetes. This moved focus from a single, doctor's appointment to a personalised, two-part care planning process. It empowered patients to self-manage, using tailored information, preparation, and structured meaningful conversations with healthcare professionals to improve patient outcomes and reduce the NHS burden. This was particularly important as the practice were in an area of high deprivation and in the area of the branch surgery there was a high proportion of patients with chronic obstructive pulmonary disease (COPD) and asthma.

The practice could demonstrate year on year that they had increased the number of LTC reviews they carried out, in 2023 – 1,656; in 2024 – 1,839; in 2025 – 2,145. Overall, in 3 years this was an increase of almost 30%.

In order to achieve this the practice used early identification via proactive management of health data to reach patients who might otherwise disengage or be missed, with a deliberate focus on closing gaps in care.

The practice introduced a housebound LTC visiting service in 2025. The practice recognised the gap in the district nurse provision; whilst being aware they had a higher-than-average elderly population. The lead nurse designed and implemented a nurse associated home visiting LTC review model. This resulted in 143 housebound LTC reviews in 2025 and 26 so far in 2026; all provided by the practice. They used frailty and risk stratification to identify the highest risk patients to ensure they received interventions first.

The holistic reviews of these patients provided checks on their physical health, continuity of care, identified social concerns, safeguarding risks, environmental safety and carer strain. They gave insight into patients’ living conditions that could not be gained in clinical settings. Concerns could be raised with social prescribers or other healthcare professionals.

The practice were to share the learning from this approach to care with the local integrated care board (ICB) and the local GP health federation now that they have a full year’s data, with a view to this approach being adopted by other practices.

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 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, including where clinical tasks were delegated to other services.

The practice explained to us in detail how the 2-week-wait and urgent referral system worked to ensure patients at risk were followed up.

We contacted a local care home for feedback on the service the practice provided to their residents. They told us they worked well together with a good relationship. Nothing was too much trouble for the practice. They did regular ward rounds and were vigilant and responsive in all aspects of end‑of‑life planning.

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. They used early identification and prevention, to target patients who would otherwise remain unseen to assess their future needs for care and support.

The practice introduced a self-check in pod in reception following a trial period of using it, gaining positive feedback from patients. This could be used independently by patients, therefore encouraging them to manage their own health.The practice also has a loan system for BP machines for patients, allowing them to self monitor and actively supports patients to monitor their BP, height and weight and other non-clinical checks at the pharmacy within the same building and in the local area.

The practice had access to a social prescriber who was non-medical, community-based and provided services to improve patient health, wellbeing, and social welfare. For example, they could help address loneliness, isolation, or practical needs like housing, debt, or unemployment.

The practice is classed as a 'deep end practice' due to the high levels of deprivation. Last year they completed a healthier lives project in collaboration with the Deep End Network and Newcastle University. The practice employed a link worker to build relationships with patients over the phone to support them to attend for health checks, which they normally would not engage with. This was a local practice based initiative to support the most socioeconomically deprived communities. The aim of the project is to identify early identification and prevention of health issues, targeting patients who would otherwise remain unseen and to tackle health inequalities.

In a year 368 checks were carried out, those displaying some early symptoms were referred for further preventative care. For example, 70 patients were identified with high blood pressure or cholesterol, 55 of these were referred for hypertension management and 13 weight management referrals were made. Three patients were referred for support with alcohol and substance misuse who would not have been picked up normally. Other local GP practices were looking to introduce a similar system based on this one.

The service monitored all people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

The practice told us attaining screening and immunisation targets could be challenging. The practice population were in the group of patients with the highest levels of deprivation, the population were transient and some patients first language was not English. They had used targeted calls to patients, some in specific languages with the help of interpreters or staff, with the practice nurse to target females who required cervical screening.

The practice provided us with unverified data for child immunisations that showed that they had almost achieved all of the minimum targets set by the World Health Organisation (WHO), for example measle mumps and rubella (MMR) vaccination for children aged 2, 93%, unverified, (target 95%). Cervical screening rates (unverified) were above the 80% target (age 25-49 83%, age 50-64 89%). This was an increase from the published data held, Child immunisations for children age 2 (2023/2024) 89.5%. Cervical screening rates for females aged 25/49, 2024, 72.3% and aged 50-64, 2024, 75.8%

The practice provided us with a list of audits they had carried out over the last 2 years. They demonstrated a strong focus on quality improvement at the practice. This included a 2-cycle audit on the prescribing of antibiotics to patients with a lower respiratory tract infection (an infection of the lungs or airways acquired outside of hospitals or healthcare facility). This 2-cycle audit led to a positive change, ensuring that NICE guidance was followed and the correct type of antibiotic prescribed.

There was a two-cycle audit of the pneumococcal vaccination uptake among patients with learning disabilities. This was carried out following guidance that patients with learning disabilities were more susceptible to pneumonia and carried higher mortality rates for this. The practice saw an uptake rising from 4.9% to over 55% after targeted interventions. This increase was supported by improved protocols, education, and patient-centred approaches.

The practice carried out a gestational diabetes mellitus (GDM) two cycle audit, aimed to assess whether patients with GDM were being appropriately clinically coded and recalled for follow up and were receiving annual blood glucose level monitoring. Initial data identified 36% of these patients were having annual testing. Following this improved recall systems, clinical coding, staff education and patient awareness of the long-term diabetes risk and importance of follow up were implemented. Blood glucose monitoring increased to 68% on reaudit. The improvements in recall systems improved from 78% patient coverage to 100% coverage on a further reaudit.

A two-cycle audit of the monitoring across all prostate-related conditions (PSA) resulted in an increase to 94% compliance with appropriate monitoring and 100% at the second audit. This was undertaken in response to a significant event following a missed PSA test for a patient with prostate cancer.

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.