Eastgate 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 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 79 (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.

Feedback from people using the service about how their needs were assessed was positive. People told us they felt involved in assessments of their needs. The 2025 GP Patient Survey showed 93% of respondents said their needs were met at their last appointment, which was above the local (87%) and national (90%) results. Patient feedback we received confirmed that people felt confident staff understood their individual and cultural needs.

Systems were in place to identify people with caring responsibilities at registration, opportunistically and through self-reporting. The service maintained a carers’ register, and 2.6% of the practice population were identified as carers.

The service had systems to identify and prioritise care and treatment for people who were vulnerable. For example, all people with a learning disability had been invited for a learning disability health check, and 100% (12 out of 12) had received a health check within the previous 12 months. Reasonable adjustments were in place to support attendance. Arrangements were also in place to invite eligible people for NHS health checks, and health checks for people aged over 75 years were available.

Staff were aware of the needs of the local community. They used digital flags within the care records system to highlight specific needs, such as the requirement for an interpreter or accessibility requirements. Reception staff provided examples of people they were familiar with and the additional support they offered, such as providing a quiet place to wait for people who found busy environments challenging due to neurodiversity. Feedback from patients confirmed this approach. The results of the 2025 GP Patient Survey showed that 96% of respondents found the reception and administrative team helpful, which was above local and national averages.

The service always 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.

Clinical staff used templates to support consideration of people’s wider health and wellbeing during care reviews.

Staff told us that the leaders provided opportunities for them to keep up-to-date with current guidelines, and changes to evidence-based care and treatment, for example through training days, clinical meetings and learning from clinical audits.The service monitored and improved outcomes for people by carrying out clinical audits.

The service operated a recall system, and staff contacted people when reviews were due, for example, for a long-term condition review and follow-up arrangements were in place for people who did not respond to invitations. Where reviews remained outstanding, the pharmacy team invited people to attend an appointment.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance. For example, there were effective systems for monitoring people with asthma, chronic kidney disease stages 4 or 5, people with hypothyroidism, and people with diabetes. We did not identify any concerns from any of the cases we looked at during our clinical searches.

The service had effective systems in place to identify people with previously undiagnosed conditions. During our search of the practice’s clinical system, we did not identify any cases of potentially missed diagnoses.

The service had a comprehensive programme of clinical audits and quality improvement initiatives to drive continuous improvement. We saw evidence that this led to measurable improvements in patient outcomes across a range of long-term conditions.

For example, over a 9-month period from April 2025 to January 2026, a pharmacist-led approach to managing patients with diabetes increased the proportion of patients achieving treatment targets from 34% to 42%. During the same period, dedicated hypertension clinics improved blood pressure control from 56% to 74%. The service also completed over 400 asthma reviews, which reduced overuse of reliever inhalers and improved asthma control, with performance in line with or above local benchmarks. This demonstrated that care was delivered in line with evidence-based guidance and was regularly reviewed and improved to achieve better outcomes for patients.

The practice had carried out a quality improvement project for patients prescribed long-term opioids. Opioids are strong pain medicines that can lead to dependence and other health risks if used for a long time. Patients took part in structured reviews with a pharmacist to discuss their pain, treatment goals, risks and wider wellbeing needs, and personalised care plans were developed through shared decision-making. Between 2023 and 2026, the practice completed more than 200 medication reviews for patients prescribed opioids. This resulted in many patients reducing or stopping their opioid medicines, with overall opioid prescribing across the reviewed group of patients reducing by almost 40%. Seven patients had stopped opioids altogether. The practice also saw a significant reduction in the number of patients prescribed high-dose opioids, helping to improve patient safety and support better long-term outcomes.

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.

The service worked with other organisations to deliver effective care and treatment. Partners we received feedback from had no concerns regarding how the service worked together with other services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. There were systems for sharing information with staff and other agencies.

The service worked with other organisations to ensure continuity of care, including where clinical tasks were delegated to other services.

Staff we spoke with described how they were proud of the cohesive team working relationships they had to ensure all patients received high quality care and treatment. They told us they were engaged and supported by leaders to be innovative and to meet patients’ needs. This positive feedback about working together as a team was also fed back by staff in their questionnaires.

Arrangements were in place for some staff from this service and other services within the Primary Care Network (PCN), with the same management team, to work across sites so they could respond to the needs of people in a flexible way.

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 supported national priorities and initiatives to improve population health. The service had a project on health events to help patients improve their health and wellbeing through health education, free health checks and community outreach. Activities included a Health and Wellness Day, a Men’s Health Event, visits to a local Gurdwara and church, and participation in a local community event. Patients received information on topics such as mental health, healthy eating, exercise, blood pressure and cholesterol, and were able to access free health screening and advice from practice staff and local organisations. The events were well attended and received positive feedback from attendees. The project helped the practice engage with a wide range of people, improve access to health information and encourage patients to take a more active role in managing their health.

The service had an ongoing project, Project Thrive, to improve support for patients with learning disabilities and autism. The service had taken steps to improve accessibility, including providing easy-read information, sensory resources and staff training. These actions had helped create a more inclusive environment and had contributed to a 100% completion rate for learning disability annual health checks. The project remained ongoing at the time of our assessment.

The service identified patients who may need extra support and directed them to relevant services, including unpaid or family carers. At the time of this inspection, the practice had 227 unpaid or family carers on the register.

The service had also undertaken a “Care for Carers” project to support unpaid carers. A dedicated Carers Champion had organised a monthly carers café, providing carers with opportunities to meet others, access support and share experiences. Partner organisations also attended and provided advice. The practice shared feedback on this, which had been very positive, with carers reporting that they felt supported and valued by the practice. The project was ongoing at the time of our assessment.

Staff encouraged and supported patients to be involved in monitoring, managing and improving their own health. Information was available on the practice’s website about local and national services that were available, including sexual health, maternity care, child health, mental health and bereavement. There was also a wide selection of leaflets and easy-to-read information available in the practice.

Staff focused on identifying risks to patients’ health, including those in the last 12 months of their lives, those at risk of developing long-term conditions and those with caring responsibilities. NHS health checks were offered to people aged 40 to 74 years.

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.

Leaders and staff showed a good understanding of their local population. They explained that the service had a rapidly growing patient list, which presented challenges in keeping pace with national targets for immunisations and cervical screening. Staff had taken a proactive approach to improving uptake and were able to demonstrate the progress they had made. Despite these ongoing improvements, performance remained below national targets at the time of inspection.

The service had not met the national targets of 95% for childhood immunisations. The most recent data from the UK Health Security Agency (UKHSA) showed uptake was:

• 89% for children aged 1 who had completed the recommended primary course of immunisations for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus influenza type b (Hib) and Hepatitis B.
• 84% for children aged 2 having received a Pneumococcal booster.
• 86% for children aged 2 having received a Hib and Meningitis C booster.
• 87% for children aged 2 having received their first dose of the measles, mumps and rubella (MMR) vaccine.
• 76% for children aged 5 having received 2 doses of the MMR vaccine.

Leaders and staff had introduced a wide range of measures, which included undertaking a childhood immunisation improvement project to help increase vaccine uptake and address misinformation. The service developed a range of educational materials, created a dedicated immunisation section on their website, and worked with local partners, including health visitors, social workers and council teams, to promote accurate vaccination information across the wider community.

The service had also developed a live immunisation tracker and used weekly recall lists to identify children who were overdue for vaccinations, book appointments, and follow up with parents to encourage attendance. Dedicated vaccination clinics were provided, and parents were offered opportunities to discuss any concerns with clinical staff.

Staff described using personalised approaches to build trust with families. For example, when a staff member spoke the same language as a parent, they used this opportunity to discuss immunisations and encourage uptake. Vaccinations were also offered opportunistically when children attended the service for other reasons, to maximise uptake.

The service was below the national targets for cervical screening. For women aged 25 to 49 years old the observed number was 72%, which was lower than the national target of 80%. For women aged 50 to 64 years old, the observed number was 77%, which was lower than the national target of 80%.

Leaders and staff had identified some reasons for the lower uptake and taken action to improve this. They undertook a cervical screening improvement project to increase uptake and improve access to screening. They used weekly recall lists and text messages with self-booking links to identify and contact eligible patients who were overdue for screening. Dedicated Saturday clinics, known as ‘Smear Saturdays’, were introduced to provide more flexible appointment options.

The service also developed an awareness campaign, including inclusive and easy-read information displayed on a health promotion board in reception. Data from the provider’s clinical system showed that the number of cervical screening tests completed had increased since 2022/23.

The service was in line with the NHS England averages for breast and bowel cancer screening, with 72% breast screening in 53 to 70 years old (national average is 70%), and 71% for bowel cancer screening for 60 to 74 years old (national average 72%).

Patients aged between 40 and 74 are eligible for an NHS health check. The practice had met its commissioned annual delivery target. Health checks for patients aged over 75 years were available only through routine clinical contacts. The service was planning to introduce dedicated over-75 health check clinics.

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. People’s feedback demonstrated they felt at ease during consultations, were listened to and procedures were explained well. People were appropriately informed when making care and treatment decisions.

Staff understood and applied legislation relating to consent. Staff were aware of the importance of ensuring a patient had given their consent before sharing information with others, and there was a system to record if the patient had given their consent. We reviewed staff training and saw that all staff had completed training in consent and mental capacity.

Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. We saw evidence that capacity and consent were clearly recorded in patient records, and staff and family members were included in decisions about care.

Chaperone posters were clearly displayed on the premises informing people this was available to them, and information was available on the website. People were offered a chaperone during examinations to support informed consent, and their preferences were respected and recorded where appropriate. (A chaperone is an impartial observer present during an examination or consultation when people may feel vulnerable, for example, during an intimate examination. A chaperone acts to protect both people and staff).