Wychbury 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.

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 and clinical staff used templates when conducting care reviews to support people’s wider health and wellbeing.

The provider had systems to identify people with previously undiagnosed conditions. There were 32 (0.1%) patients identified by our clinical searches as having the potential for a missed diagnosis of diabetes. We sampled 4 of the 32 records and found these to be satisfactory, however interval testing and coding required further review to ensure this was robust.

Our clinical searches found 14% of the total number of patients with diabetes (1734) with a high blood sugar monitoring result (HbA1c >75mmol/l). We sampled 4 of the records and found these to be well monitored with processes in place.

There were 7 patients (0.7%) with hypothyroidism our clinical searches identified as having the potential for not having had thyroid function test monitoring for 18 months. We sampled 3 out of the 10 records. 1 patient had been reviewed and 2 had recall reminders in November 2025.

There were 6 patients with chronic kidney disease at stage 4 or 5, who had the potential to have not had blood test monitoring in the last 9 months, (6%). We reviewed 3 records and found that 1 patient had been reviewed, 1 patient was only just due a review and the other patient required follow up.

The total number of patients with asthma who had been prescribed 2 or more courses of rescue steroids, was 138 (2.6%). We sampled 4 of the 138 records and found them to be satisfactory.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. Social prescribers provided information on local services and activities and how to access local community groups.

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. 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. 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.

Systems were in place to identify individuals with caring responsibilities, who were offered an annual review. All patients with a learning disability were invited to attend an annual health assessment.

There were appropriate referral pathways to make sure that patients’ needs were addressed. We spoke with staff who were able to describe the process for coding of correspondence and care and treatment records for people.

Staff we spoke to were aware of the workflow and the buddy arrangements in place for reviewing and actioning test results in line with the provider’s code of practice. Clinical staff were able to demonstrate how the practice provided further education and support to patients. We found that staff had the appropriate skills and training to carry out reviews where appropriate.

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. They worked to develop evidence-based good practice and standards.

Staff were supported to keep their clinical practice up to date through training and regular updates on evidence-based guidance. This included updates on relevant guidance from the National Institute for Health and Care Excellence and other national best practice recommendations. Clinical teams had access to resources and in-house sessions to ensure that care delivery reflected current standards and supported safe, effective outcomes for people. 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 told us that they had access to the information they need to appropriately assess, plan and deliver people’s care, treatment and support and they had enough information to plan and refer people and receive subsequent results and information following referral.

There were systems and processes in place to enable information to be shared between the provider and services to ensure continuity of care. Regular meetings were held with multi-disciplinary teams to ensure care was co-ordinated effectively.

The practice was supported by the Primary Care Network (PCN), which provided access to a range of roles including pharmacists, paramedics, care coordinators, nursing associates, GP assistants, social prescribers, first contact physiotherapists, and first contact mental health practitioners. This enabled patients to receive coordinated care across the practice and the wider network.

The practice ensured that both directly employed staff and those aligned through the PCN felt integrated into the team. They were given access to staff policies and practice newsletters and bulletins, offered clinical mentoring, and invited to participate in relevant practice-based meetings and training events.

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.

Staff actively signposted patients to local support services offering information, education, and tailored advice based on individual needs. Patients were encouraged to participate in national health initiatives, such as cancer screening programmes and childhood immunisations.

The practice had designated leads with specialised knowledge, including a Carers Lead and a Menopause Champion. Additional leads covered key clinical and social areas such as respiratory care, diabetes, dementia, heart failure, learning disabilities, domestic violence, chronic kidney disease, and hypertension.

The latest GP Patient Survey carried out, showed that 92% of respondents felt their needs had been met during their last general practice appointment which was above the local average of 88% and the national average of 90%.

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 was below the national target of 80% uptake for cervical screening in 2023 and 2024, achieving 66.4% for patients aged 25-49 and 68.9% for those aged 50-64. Cervical screening performance was reviewed during the practice’s strategy meetings, where high non‑attendance rates were identified as a key challenge.

Systems and processes were in place to recall patients and implement flagging procedures to promote opportunistic uptake. Cervical health promotion boards were displayed in reception areas in multiple languages, Saturday clinics were offered, and information was sent to patients in distinctive ‘pink’ materials to encourage engagement. Strategies were also discussed with the patient participation group (PPG) to strengthen community involvement.

In relation to childhood immunisations, the practice had achieved 4 out of the 5 national targets with a range of 89.7% to 94%.

The practice had an established programme of clinical and non-clinical audits and action plans aimed at driving continuous improvement in patient care and operational efficiency. 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 service told people about their rights around consent and respected these when delivering person-centred care and treatment.

We found capacity and consent were clearly recorded in patients’ records and ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions were appropriate and made in line with relevant legislation. Appropriate discussions had been held with patients (and/or their carers) about DNACPR decisions, and the mental capacity of patients was considered. ReSPECT forms (Recommended Summary Plan for Emergency Care and Treatment) were also completed appropriately.