Stokesley 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 with advice and support. We checked staff regularly reviewed patients’ care and worked with other services to achieve this.

Art our last assessment, we rated this key question 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 practice made sure patients’ care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

The practice asked patients about their preferred communication methods or formats. Staff used digital flags on relevant patient care records to highlight any specific needs. For example, the requirement for a longer appointment.

Staff were aware of the needs of their local community. They signposted patients towards appropriate support routes. Staff proactively identified patients with caring responsibilities to offer them support.

The practice offered patients appropriate health checks.

Patients with a learning disability were offered an annual health check. The practice had a designated learning disability lead who could help patients and their families understand the process involved and feel more comfortable.

Clinical staff used templates when conducting care reviews to support the review of patients’ wider health and wellbeing needs. When completing annual reviews for patients with a long-term condition, staff used this as an opportunity to sensitively determine if patients were socially isolated or otherwise vulnerable. Staff referred patients with social needs to the social prescribing team.

Feedback from patients was positive. Patients felt involved in any assessment of their needs. They felt confident staff understood their individual circumstances. The GP Patient Survey showed 99% of Stokesley Surgery’s patients felt the healthcare professional they saw had all the information they needed about them during their last appointment. This was higher than the local and national result of 92%.

The practice did not always deliver care and treatment to patients in line with evidence-based good practice and standards.

As part of our assessment, a CQC GP Specialist Advisor completed a series of patient clinical record searches.

We identified many patients as having a potential missed diagnosis of chronic kidney disease (CKD), stage 3, 4 or 5. Although the practice was able to evidence that some of these patients had received appropriate recording of their kidney function and that relevant action had been taken, they acknowledged many patients had not been recorded correctly as having CKD. The provider took immediate steps to ensure a more robust process was put in place to correctly identify and support relevant patients in the future.

The practice had 772 patients on the asthma register. Asthma is a condition which affects the airways in the lungs. We found 36 of these patients had been prescribed 2 or more courses of rescue steroids in the last 12 months. Not all these patients had received the appropriate review to check their response to treatment. However, the provider had already identified this as an area which required improvement. They had a robust plan in place to ensure relevant patients would receive a review within 48 hours in the future.

We found the 5 patients whose records we looked at in detail had all had an annual asthma review.

One patient with asthma told us, “my symptoms are better managed than at any time I can recall, which allows me to take part in my own well-being by doing lots of walking and other exercise.”

Findings from the clinical searches confirmed the practice ensured appropriate monitoring of patients with hypothyroidism (abnormally low activity in the thyroid gland which can affect development); diabetes (a disease due to blood sugar being too high); and those with stage 4 or 5 CKD.

The practice worked well across teams and services to support patients. They made sure patients only needed to tell their story once by sharing their assessment of needs when patients moved between different services.

Staff had access to information they needed to appropriately assess, plan and deliver patients’ care, treatment and support. The practice held regular meetings with staff to update them.

The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. They had robust Shared Care Agreements and processes in place.

We received positive patient feedback about the quality of care and support provided across services. A patient praised the GPs involved in their care for, “prioritising urgent referrals and giving continuity of care.”

A patient told us, “A query regarding my medication was resolved with an appointment with the on-site pharmacist… I receive a good service.” Another patient said, “Over the past year, I have accessed consultations with the Practice Nurse, HCA, GP and physiotherapist, all of whom were kind and understanding. The Reception team always manage to be helpful and have helped me navigate and make appropriate appointments.”

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

Patients had access to weighing scales and a blood pressure monitor in the waiting area. The practice advertised several health and wellbeing initiatives on information screens, their website, and via their social media channels.

The practice supported patients to live healthier lives and, where possible, reduce their future need for care and support. They ensured staff had access to relevant information to signpost patients to additional support based on their needs. Staff also referred patients with social needs to the social prescribing team.

Staff supported national priorities by opportunistically asking patients about smoking and directing them to smoking cessation services where appropriate. Clinical staff with specialist diabetes training focused on proactively encouraging and supporting patients with regards to weight management.

The practice identified risks to patients’ health, including patients at risk of developing a long-term condition, those with caring responsibilities, and those in the last 12 months of their lives. The social prescribing team provided support to patients with caring responsibilities and ensured they were given appropriate information to assist them.

The practice routinely monitored patients’ care and treatment to continuously improve it. They ensured outcomes were positive and consistent and that they met both clinical expectations and the expectations of patients.

Findings from our clinical searches showed patients received appropriate monitoring for high-risk medicines to ensure the effectiveness of the medicines and identify any adverse reactions. They generally ensured effective annual monitoring of patients with long-term conditions.

For patients deemed pre-diabetic, the practice used a recall system and signposted them to the social prescribing team to offer early intervention.

For patients found to have borderline raised blood pressure, the practice actively monitored them. If diagnosed, patients received an annual recall to review their health.

The practice completed medication reviews for patients when appropriate. They monitored the use of antibiotics to optimise care outcomes. The practice had recently begun re-assessing the process of prescribing controlled drugs to ensure better monitoring of relevant patients.

The practice failed to meet national targets for screening and immunisations.

Based on the latest verified NHS England data (from 30 June 2024), the practice was slightly below the 80% target for adequate cervical screening in women aged 25 to 49 years (78.5%), and for women aged 50 to 64 years (78.8%). However, we were satisfied the practice had attempted to contact the relevant patients. They had delivered various initiatives to try and encourage more women to participate in this important screening programme.

Based on the latest verified UK Health Security Agency data (from 1 April 2024 ~ 31 March 2025), the practice failed to meet the 90% minimum uptake target expected for all 5 childhood immunisations. However, we were satisfied the practice had repeatedly encouraged parents to immunise their children. They had attempted numerous methods to engage with relevant patients. Additionally, there were relatively low numbers of patients who were children. This negatively affected the practice’s overall target figures when some families chose not to accept immunisation. When appropriate, the practice raised any concerns with health visitor and safeguarding colleagues.

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

The practice had a consent policy in place giving clear information for staff about the different forms of consent a patient may give and how a patient may withdraw it any time. There was a formal consent form available for patients to complete when having specific procedures (such as minor surgery).

A recent comprehensive audit relating to consent showed good staff compliance in gaining and recording of patient consent. It also highlighted areas of improvement the practice wished to work on. This included the potential use of artificial intelligence (AI) tools in the future to make the recording of consent more efficient.

All staff had received training in the Mental Capacity Act. The mental capacity of patients was considered.

When appropriate, staff discussed consent with a patient’s family, during multi-disciplinary meetings, and during any best interest meetings involving social services. The practice checked for relevant power of attorney evidence when required.

We found ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) decisions were appropriate and made in line with relevant legislation. We saw evidence that appropriate discussions had been held with patients (and/or their carers) about DNACPR decisions.