City Way Surgery

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 patients in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed patient’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed.

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 practice made sure patients’ care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Patient records we looked at showed they were appropriately coded and flagged to alert staff to individuals’ needs and preferences. Vulnerable groups were proactively invited for health checks, such as carers and those with long term health conditions.

During our remote clinical searches, we reviewed a sample of mental health reviews and found they were thorough, person-centred and of good quality.

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.

Staff checked patients’ health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of patient’s wider health and wellbeing.

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. Our remote clinical searches conducted on 3 December 2025 showed that patients with long‑term conditions were being effectively monitored.

The practice worked with other services to ensure continuity of care, including when clinical tasks were delegated to other services, including those who may be vulnerable because of their circumstances.

Staff had access to the information they needed to appropriately assess, plan, and deliver patients’ care, treatment, and support.

Staff described positive working relationships and clear communication pathways with community colleagues. For example, escalating safeguarding concerns, which helped ensure concerns were addressed promptly and appropriately.

We saw positive feedback from the local safeguarding team regarding the quality and clarity of the referrals made by the practice, which supported effective safeguarding processes.

The practice supported patients to manage their health and wellbeing to maximise their independence, choice and control. The practice supported patients 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.

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

UK Health Security Agency data showed between April 2023 and March 2024, the practice met the national minimum threshold target for 4 out of 5 childhood immunisation indicators, achieving 94%. For the remaining indictor, the practice performed at 83%, which was below the minimum target of 90% (World Health Organisation recommends a rate of 95% for all routine childhood vaccinations). The practice demonstrated awareness of the contributing factors and took steps to improve uptake. For example, clinicians proactively contacted parents/guardians/carers to address concerns or questions and made use of opportunistic moments to offer and administer vaccinations.

The practice had a system to track vaccination status and monitor all patients requiring follow‑up. These records showed ongoing analysis of uptake trends and a structured approach to identifying and recalling individuals who were overdue, supporting the practice’s efforts to improve coverage.

NHS England data showed the practice was performing below the 80% national target for cervical cancer screening uptake as of June 2024. It showed it had achieved 69% coverage for women aged 25-49 and 75% for women aged 50-64. The practice carried out regular recall audits and took steps to improve uptake, including routinely inviting patients, holding conversations to explore concerns and offer reassurance, and sending text messages with self‑booking links.

Unverified data from the practice dated 13 December 2025 showed an improvement in uptake; the practice had achieved 78% uptake for the eligible population aged 25 to 49 years and 80% for those aged 50 to 64 years (unverified data refers to data that has been provided by the practice and has not been published, therefore has not been verified by the data owner, for example, UK Health Security Agency, NHS Digital, NHS England and Improvement).

The practice had a programme of targeted quality improvement and used information about patient care and treatment to drive changes. An audit completed in December 2024 reviewed the quality of ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) forms, focusing on the completeness and clarity of information recorded. The audit identified areas for improvement, including ensuring healthcare professionals’ signatures were consistently applied and ensuring the key elements of ReSPECT conversations were clearly documented. A re‑audit in June 2025 demonstrated improvement. The proportion of forms without a healthcare professional’s signature reduced from 55% to 6%, and the proportion lacking a recorded clinical recommendation reduced from 25% to 6.7%.

The practice told patients about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. A review of a sample of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions found that they were appropriate and made in accordance with relevant legislation and best practice guidance.