Cape Hill Medical Centre

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

84% of patients who completed the National GP Patient Survey said their needs were met during their last GP appointment. This was slightly lower than the local average of 88% and the national average of 90%.

Additionally, 92% of patients felt the healthcare professional had all the information they needed about them during their last general practice appointment. This was slightly higher than the local average of 91% and in line with the national average of 92%.

People we spoke with felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. 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. Reception staff were aware of the needs of the local community and staff working at the practice spoke a range of languages which provided support to the local practice population. 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 systems in place to identify people with previously undiagnosed conditions. Care plans and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) records were completed and reviewed regularly. 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 found that staff had the appropriate skills and training to carry out reviews where appropriate.

The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

During the remote clinical review, we carried out a search to identify people with asthma who had been prescribed 2 or more courses of rescue steroids in the past 12 months. The search identified 43 people. We reviewed a random sample of 5 clinical records and found 2 patients had not had a follow up review following an exacerbation.

We carried out a clinical search on patients who had hypothyroidism and had not received the appropriate monitoring in the past 18 months. The search identified potentially 11 people. We reviewed 5 clinical records and found 3 patients had not received the appropriate monitoring.

Further reviews of the clinical system identified people with diabetes who had a HbA1c of 75 and over. A haemoglobin A1C (HbA1C) test is a blood test that shows your average level of blood glucose over time. The search identified 151 people. We reviewed a random sample of 5 clinical records and found the appropriate reviews had been completed.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was generally 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 they had access to the information needed to appropriately assess, plan and deliver care, treatment and support. They also had sufficient information to refer people and receive results and updates following referral. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

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 Primary Care Network (PCN) helped to support the practice by providing links to pharmacists, physiotherapists and social prescribers. People were able to receive co-ordinated care between the practice and the PCN.

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, 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 made reasonable adjustments to provide support to vulnerable patients. This included home visits for patients who were unable to attend the practice.

The practice had been involved in a range of initiatives. This included:

• The practice had hosted a women’s wellbeing event in June 2025. The event was held to provide information to females in the local community on menopause support, cervical and breast screening programmes, local community services and health education. A range of community services joined the event, for example public health and Age UK. A total of 133 patients attended the event. Following the event, 3 patients received blood pressure readings, 3 patients attended cervical screening appointments and 5 patients were referred for weight management. Another 50 patients were signposted to a range of local services to improve health and wellbeing. These included physical activity, stop smoking services and diabetes UK.
• The practice had developed a maternal health service called the Ayub project to provide support for women during pregnancy and the first years of their child's life. The aim of the project was to support patients who had social issues, maternal poor nutrition, insufficient exercise and previous poor outcomes, for example miscarriage. An audit was completed to identify patients that would benefit from a personalised support approach. The audit found 12 patients had had a previous poor outcome in pregnancy, 10 patients had concerns related to safeguarding and 21 patients had a comorbidity, including thyroid disease, hypertension, diabetes and a raised BMI. The practice contacted all female patients aged between 18 to 50 years who had a long-term condition such as diabetes to provide them with information they would need to consider if they were planning a pregnancy. The social prescribing team ran this service alongside the midwifery antenatal sessions to identify pregnant women. The project also accepted referrals from the wider clinical team should a parent or child need ongoing support.
• The practice had actively been involved in the Workwell project with 2 other practices within the Primary Care Network (PCN). The aim of the project was to reduce long-term sickness absence and support patients to remain in or return to work with referrals to local support organisations. Patients who agreed to take part in the project were provided with a GP consultation to review their individual needs. Social prescribers were involved to provide patients with extra support. The project had started in August 2025. At the time of the onsite assessment, the practice had referred 19 patients and 25% of the patients had progressed through the programme and were looking for work.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The practice was below the national target of 80% uptake for one of the cervical screening indicators with the practice having achieved 73.5% for people aged between 25 to 49 years of age. For people aged 50 to 64 years, the practice had achieved 80.6%. To encourage people to attend their appointments, appointments were available at different times throughout the week to provide choice and a range of availability. The practice had not achieved 4 out of the 5 national targets for childhood immunisations. For example, the latest data available showed the practice had achieved 84.8% for children aged 2 who have received immunisation for measles, mumps and rubella. This was below the 90% minimum target. Patients that failed to attend appointments were followed up and information was shared with the health visiting team.

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.

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.