Southlands 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 remains the same.

This service scored 75 (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 and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community. They 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. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. 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 practice held weekly whole-clinical-team meetings, rotating between Monday and Thursday to ensure staff attendance. There were discussion of cases including, palliative patients, cancer reviews and urgent cases.

There were multi-disciplinary team (MDT) meetings looking at care home patients who the pharmacist took the lead to monitor, frail and housebound patients.

The clinical team between them had specialisms which included respiratory, frailty, minor surgery, diabetes, palliative care, paediatrics and emergency medicine.

The 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. Clinical records we saw demonstrated care was provided in line with current guidance.

We saw examples of clinical audits. The practice provided us with a list of audits carried out in the last year; there were 16 in total. For example, the practice carried out an audit of patients who were prescribed long-term antipsychotic medication after discharge from local mental-health services. They had identified a safety gap. As a result of the audit the practice moved from inconsistent, register-dependent monitoring to a dedicated antipsychotic register and recall process.

The practice carried out an audit of the medication used for breast cancer treatment. They wanted to be sure that the review dates for the medication were followed, and treatment was stopped as appropriate. As a result, 7 letters were sent to the patient’s consultant for follow up as the medication had exceeded the duration of treatment.

Other audits included, for example, monitoring of long-term steroid therapy patients and reducing long term use of inappropriate anti-inflammatory medication.

The practice reviewed every cancer diagnosis case. As part of the review, they looked back over the previous 2 years to identify whether anything could have been done better and to capture learning opportunities.

The practice proactively carried out searches of registers to identify patients with complex conditions who may be outside of the regular standard searches. Results were discussed at clinical meetings.

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.

We contacted a care home where the practice had patients as residents. The care home manager told us the practice were very responsive and caring for the residents and they had a good relationship; nothing was too much trouble, particularly when a resident was unwell.

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, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The practice had introduced a self-check in pod in reception. Non-clinical checks could be performed in the pod such as blood pressure and body mass index (BMI) using weight and height. This could be performed independently by patients, therefore encouraging them to manage their own health.

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

The practice exceeded national targets for screening and immunisations. For example, the percentage of children aged 1 who had completed a primary course of immunisation for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus influenza type b and Hepatitis B was 100% (from 116 children) compared to the target of 95% (1 April 2024 to 31 March 2025).

Cervical screening rates (unverified) were above the 80% target (age 25-49, 84%, age 50-64, 83%). This was an increase from the published data held and was from April 2026 to 31 July 2026.

From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The practice 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.