Nethergreen Surgery

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• 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 staff involved people in decisions about their care and treatment and provided them with 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.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

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. For example, some patients took part in a healthy walking programme, and the lead nurse had delivered cooking demonstrations as part of a dietary support group to promote healthy lifestyles.

Staff focussed on identifying risks to people’s health, including those in the last 12 months of their lives 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 outcomes were positive, consistent and met the expectations of people themselves. The service operated a system of annual birthday reviews, enabling all required checks for long-term conditions, medication monitoring tests, and outstanding screening to be identified and completed in a single, appropriately timed appointment based on patient need. Pre-appointment questionnaires were also used for certain conditions, such as asthma and hormone replacement therapy (HRT).

The service maintained a programme of regular clinical audit and research focused on improving patient outcomes. For example, a clinical tool was used to identify patients under 75 with elevated cholesterol levels who were not receiving lipid-lowering therapy; this identified 16 patients in May 2025, reduced to 5 by September following intervention. The service also undertook quality improvement work, including identifying and reviewing patients with potential undiagnosed chronic kidney disease through blood test analysis.

The service met national targets for the uptake of childhood immunisations achieving 98% for those aged 1 and 97% for those aged 5 years and 94% for those aged 2 years (World Health Organisation target 95%). The service had met the national target of 80% for screening of cervical cancer for those aged 50 to 64 years and was achieving just below the national target at 74% for those aged 25 to 49 years. The provider was aware cervical cytology screening for those aged 25 to 49 years was below national target and had worked within their primary care network (PCN) to promote this. Through the PCN, social prescribers had attended the practice to distribute promotional materials and proactively contacted patients who were overdue by telephone to support appointment booking. They also utilised text messaging, including a direct booking link, to make access more convenient and reduce the need for patients to contact the practice by phone.

The service had exceeded national standards for breast and bowel screening uptake with 82.4% uptake for breast screening (national average 70.4%) and 85.9% for bowel screening (national average 71.8%). The service had sent out via text message, information on the NHS screening programmes for people who were trans or non-binary to explain who was invited for screening through NHS screening programmes.

The service also had positive outcomes with prescribing rates showing no statistical variation to national averages for psychotropic medicines, gabapentinoids (prescription medicines primarily used to treat neuropathic pain (nerve pain), epilepsy, and anxiety), and antibiotics, although broad‑spectrum antibiotic prescribing was slightly above average. The service had participated in national prescribing quality improvement schemes, to optimise prescribing and improve patient outcomes.

Non-clinical staff demonstrated a good understanding of how to recognise a deteriorating patient, including signs of sepsis. While formal training records were not available, clear and accessible guidance, such as posters, were in place to support staff. An appointment protocol was in use, and although formal care navigation training had not been recorded, staff demonstrated strong knowledge of how to prioritise urgent cases. Their experience, combined with consistent access to a duty doctor, supported effective decision-making and the service had a plan to formalise and record training in these areas.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.