St Margaret's Medical Practice

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. Staff explained that the reviews went beyond clinical checks to look at each person’s wider wellbeing, making the discussions personalised. They also offered education and information, including signposting to the NHS Diabetes Prevention Programme, a structured, multi‑week group course with dietitian support and resources such as booklets and recipes.

Feedback from people using the service was positive. Recent results from the National GP Patient Survey showed that 96% of people felt they were involved as much as they wanted to be in decisions about their care and treatment at their last GP appointment.

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. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The practice held monthly target‑setting meetings that focused on key practice priorities. These meetings were described as also acting as a form of patient risk assessment. They were used to review performance and to develop action plans for each indicator, aimed at improving monitoring and recall for people with long‑term conditions. This explicitly included diabetes and asthma reviews, as well as other long‑term conditions.

The practice also described holding a diabetic multidisciplinary meeting for patients who had been newly started on insulin and for those with complex or challenging treatment regimes.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

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. Staff told us they maintained their professional knowledge through regular revalidation and attending clinical meetings.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. The practice was signed up to receive safety alerts and received updates from CQC and NHS England. 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 described close joint working with Primary Care Networks (PCNs) roles and community services, supported by shared clinical systems that allowed access to shared records.

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. Coordinated care was delivered through collaboration with a range of professionals and services, such as physiotherapy and mental health practitioners, district nurses, intermediate care services to prevent hospital admissions, and community‑based specialist teams.

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.

This included delivering webinars to engage patients on relevant health topics. An autumn session for parents provided advice on children’s health, including recognising warning signs that may indicate a serious or urgent condition, self‑care guidance, and signposting to services such as Pharmacy First and NHS online resources.

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 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.

Whilst the service was below some national targets, such as childhood immunisation rates, staff described actions they had taken to improve uptake. This included recalling families through repeated invitations and follow‑up letters, alongside direct GP contact to discuss concerns and encourage attendance. Vaccine hesitancy was addressed through patient education, including a webinar for parents that covered children’s health, red‑flag symptoms, self‑care, and signposting to services such as Pharmacy First and NHS online resources.

Similar action was evident in relation to cervical screening. Staff promoted participation through education during consultations, written information, and proactive text and letter reminders. Flexible appointment options, including extended hours were offered to improve access. The practice had been accepted to introduce home cervical screening test kits and told us this was due to be implemented in the near future to improve accessibility for patients who found in‑person appointments difficult.

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. Staff told us they were able to adapt or translate information about care and treatment so that people could understand, to support them making informed decisions. Staff reported that they were encouraged to seek support from a clinician whenever they required additional guidance. All staff we spoke with had completed relevant training and were able to discuss how to gain informed consent for treatment. We reviewed a random sample of staff training records which showed almost all staff had up-to-date training on Mental Capacity Act (MCA). We saw that consent was recorded and processes were in place for chaperones to be present if requested.