Stokesley Surgery

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence the practice met patients’ needs, and that staff treated people equally and without discrimination.

At our last assessment, we rated this key question as good. At this assessment, the rating has changed to outstanding.

This service scored 89 (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 were at the centre of their care and treatment. In partnership with their patients, staff decided how to respond to any relevant changes in people’s needs.

Staff understood the needs of their patients. Care records reflected any relevant additional needs of patients. Staff referred patients with social needs to the social prescribing team for support.

Feedback from patients and our review of clinical records showed patients were supported to understand their condition and were involved in planning for their care needs. Patients were involved in discussions about their care.

The ‘Friends and Family Test’ feedback from patients gathered by the practice reflected a high level of patient satisfaction.

Some examples of comments made by patients were:

“Clear and easy to understand discussion.”

“[GP] always gives the time, attention and understanding to the complexity of multiple simultaneous symptoms. [They] never [make] me feel rushed.”

“Seen promptly and my appointment with the nurse was thorough and left me with a clear understanding as what my plan going forward is.”

“I was worried about the visit…. But [staff member] was really good and talked me through the process and while [they] did that the injection was over. Really good.”

The practice had an exceptional understanding of the diverse health and care needs of its patients and the local community. They had a multi-disciplinary team to manage the diverse needs of its patients. Staff attended regular meetings to discuss and arrange support for patients with complex social needs.

The practice utilised staff provided by the Primary Care Network (PCN) to provide additional support for patients who needed it. As part of the PCN, the practice looked at population health data to assess patient need. Due to the practice’s elderly population and high proportion of frail patients, the practice prioritised these patients.

Staff attended fortnightly meetings (with clinicians, community nursing team, ‘Hospital at Home’, social services, the palliative care team, and any other relevant partners) to determine how best to help these patients. As such, relevant patients received home visits from clinicians when required, as well as additional support from the social prescribing team and community services.

The practice had a dedicated advanced nurse practitioner (ANP) who led on providing support for frail patients. The ANP was supported by the care co-ordinator who had received Clinical Frailty Scale training. Social services and the local extra care housing service could contact these staff directly with any concerns.

Staff produced monthly reports of the frailty register to ensure that any patients admitted to hospital were checked on. All patients with severe frailty or dementia received a face-to-face annual frailty review (usually in their own home) by the ANP. This was a comprehensive geriatric assessment which reviewed health needs, carer support in place, financial / funding opportunities, any Lasting Power of Attorney documentation, and ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) decisions if appropriate. If needed, the ANP completed emergency healthcare plans which were left at the patient’s home, as well as being uploaded to Stokesley Surgery’s clinical system to ensure all clinicians were aware of the plan.

Any patients with mild or moderate frailty were seen face-to-face by the ANP following any hospital admission or ambulance call-out.

Stokesley Surgery had 508 patients on their frailty register at the time of our assessment, with 51 of those deemed to be severely frail. In the past 12 months, the practice had completed 107 comprehensive geriatric assessments. Information compiled by the local Integrated Care Board showed Stokesley Surgery had a lower proportion of hospital admissions for their patients than in other areas of North Yorkshire.

We saw the practice worked in partnership with other services and community groups to ensure care and support for patients was joined-up, flexible and supported choice and continuity.

Stokesley Surgery had received ‘Armed Forces veteran friendly’ accredited status. This meant they had a dedicated clinician with knowledge of military-related health conditions and veteran-specific health services. This ensured veterans received appropriate care, treatment and support to meet their needs. Every patient is asked when they register if they are a veteran. Those patients who were veterans (65 at the time of our assessment) received an offer of support from a GP and / or the social prescribing team.

The practice was working with Healthwatch (an independent champion for people using health and social care services in England) and Hambleton Community Action (a local charity focused on tackling isolation, especially in rural areas) to try and reach more patients in the local farming communities. Stokesley Surgery wants to establish how they can improve access and promote healthcare for this group of people. They are currently approaching all patients to establish of list of those who are farmers and to determine the type of farming they are involved in. This will identify potential seasonal impacts and likely availability of farmers which the practice will consider when promoting and delivering health campaigns, as well as creating campaigns aimed at this specific group of patients.

The practice is also part of a cancer incentive scheme which involves completing a quality improvement project to review cancer screening and treatment in the farming community.

The practice supplied appropriate, accurate and up-to-date information in formats tailored to individual patient needs.

In conjunction with clinical research, the practice took on an active role in digital innovation and patient engagement. They were selected as a pilot site for an NHS App messaging trial via AccuRx. This proved successful both in enhancing communication with patients and in increasing uptake of the NHS App. Stokesley Surgery confirmed an increase in patients using the NHS App compared to the previous year, from 60% to 67% of patients over the age of 13 now registered.

To support wider digital inclusion, Stokesley Surgery partnered with Community First Yorkshire whose volunteers held drop-in support sessions at the practice to assist patients adopt and use digital health tools (primarily the NHS App). This collaboration was valuable for patients who may otherwise have faced barriers engaging with digital healthcare tools. The project achieved immediate positive outcomes, successfully helping patients download, register and navigate health applications. This reduced patient frustration, increased digital confidence, and empowered patients to manage their health online.

Staff recorded the communication preferences of patients on their care records when appropriate.

The practice had processes in place to ensure they complied with the Accessible Information Standard (AIS). The AIS sets out how NHS and adult social care services should identify, record, flag, share, meet, and review people’s information and communication needs.

The practice had access to interpreter services. They could also provide information translated into other languages if required. Patients could access the information on the practice’s website in different languages.

Patients could request information in large print, easy read format, audio recording or braille if required.

The patient feedback we received indicated people felt they had appropriate information about their care.

One patient told us, “The doctors and nurses are excellent and take the time to answer any questions you ask and explain so you understand what is wrong and how they are going to help you.”

In ‘Friends and Family Test’ feedback gathered by the practice, one patient said after their appointment, “Very informative [staff member] who informed me as to what bloods were being taken for, and explaining what the results would mean.”

The GP Patient Survey showed 96% of Stokesley Surgery’s patients knew what the next step would be after contacting their GP practice. This was higher than local (86%) and national (83%) results.

The practice was exceptional at enabling patients to share feedback and ideas, or raise complaints about their care, treatment and support. They looked closely at patient feedback responses and patient survey outcomes to determine areas for improvement.

‘Friends and Family Test’ feedback gathered by the practice reflected significant patient satisfaction regarding people feeling listened to by staff.

The practice’s governance policy clearly outlined the importance of shared decision-making by clinicians and patients working together. The practice had made a commitment to engage in this process to improve patients’ experience and health outcomes. This process empowers patients with the knowledge and information about their healthcare and the decisions available to them.

Patients could submit feedback or complaints in person (anonymously via a box on the front desk if preferred), via email, or by raising the matter to a member of staff. The practice also had a ‘Friends and Family Test’ link on their website which allowed patients to submit anonymous feedback.

The practice ensured regular engagement with their Patient Participation Group (PPG) to seek new ideas and suggestions from members and to gain their feedback on proposals to any changes planned at the practice. We received incredibly positive feedback from PPG members which highlighted how much the practice valued their comments and input. They told us the staff invested time in helping them understand processes so they could work together on future plans and improvements

Another said, "The practice includes the PPG well on decision making in respect to accessibility; proposals to improve communications; messaging; appointments; patient recruitment and environment. "

PPG members valued the meetings, with one saying, “The meetings, and the preparations beforehand, are carried out very professionally and taken seriously. We can see how much work has gone into them.”

The practice managed complaints in line with their policy. They ensured they reviewed the (few) complaints they received and used them as an opportunity to investigate what went wrong and work to improve their services and patient experience in the future.

For example, the practice changed their text message to patients following feedback to help patients understand the purpose of the message and alleviate any anxiety.

The practice shared learning outcomes with staff. Staff could give us multiple examples of learning from a complaint or incident where there had been an improvement made to patient care.

We observed one of the positive changes made following a complaint. This involved the purchase of some new chairs with arms and high backs to improve comfort for patients in the waiting area.

The practice was exceptional at ensuring patients could access the care, support and treatment they needed when they needed it. Patients could access the service to suit their needs. For example, in person, via telephone or online.

Patients with a learning disability could have a longer appointment, as well additional support from the advanced nurse practitioner (ANP) and the care co-ordinator. These patients were offered an annual health check at either the practice or the patient’s home. Staff ensured relevant family members and / or carers were involved in ensuring appropriate support was provided to people. They helped patients better navigate the healthcare system. They developed good relationships with patients and their families to help them better understand what was happening and try to alleviate any anxiety about attending appointments. For patients with more complex needs, multi-disciplinary team meetings (including carers and social services) were held to discuss the best course of action, including support with funding requests for continuing health care. The ANP spent a day at a new local supported living facility during flu season to comprehensively review all patients’ care needs and to provide vaccinations.

The practice had 36 patients who were registered as having a learning disability. All these patients had been offered an annual health check. At the time of our assessment, 34 patients had accepted this offer and received a review.

The GP Patient Survey showed 91% of Stokesley Surgery’s patients described their overall experience of contacting their GP practice as good. This was significantly higher than the local (72%) and national (70%) results.

Stokesley Surgery had a variety of appointments available to suit patient needs, including same-day appointments. The practice ensured there were ‘embargoed’ appointment slots available each day for patients who needed to be seen on the same day.

On the afternoon of the day we visited the practice, there were still appointments available for patients to see the duty doctor. The next available routine telephone appointment with a GP was 2 days later. The next available routine in-person GP appointment was a week later.

The practice was open 8am to 6:30pm, Monday to Friday. Stokesley Surgery also participated in ‘Better Access’. This offered patients additional options for routine appointments from 6:30pm to 8pm, Monday to Friday, as well as on Saturdays and some Sundays (either held at the practice or other local ‘hubs’). This included appointments at a respiratory diagnostics hub and a menopause clinic.

The practice regularly reviewed their telephone data to ensure patients could easily speak to staff. This showed the longest wait time patients had when calling the practice between December 2024 and September 2025 was 104 seconds.

All treatment rooms were situated on the ground floor. The practice’s waiting area, corridor, and consultation rooms were accessible. The main doors to the premises were automatic.

Staff and leaders actively listened to information about patients who were most likely to experience inequality in their experience or outcomes. The practice tailored their care, support and treatment in response to this.

Staff treated patients equally and without discrimination. They understood the importance of providing an inclusive approach to care. Staff made adjustments for patients to support equity in people’s experience and outcomes.

The practice ensured patients could register with them, including those in vulnerable circumstances (such as homeless people and Travellers). The practice only ever declined registration to patients who lived outside of the relevant catchment area.

The practice had received relatively few complaints from patients. They dealt with these in line with their policy. Investigations and learning from complaints and relevant incidents showed patients’ concerns and complaints were treated fairly and equally.

Leaders proactively sought ways to address barriers to healthcare experienced by its patient population. The practice had worked on initiatives to engage with and support patients who were frail, obese and pre-Diabetic, from the farming community, and local parents.

Patients were supported to plan for important life changes, so they had enough time to make informed decisions about their future (including at the end of their life).

The records we reviewed showed patients were supported to consider their wishes for end-of-life care. This included decisions over whether they would like cardiopulmonary resuscitation in the event their breathing or heartbeat stopped.

The practice had policies in place relating to palliative care (for patients at the end of their life) and decisions around ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR). We saw evidence that appropriate discussions had been held with patients (and/or their carers) about DNACPR decisions.

Staff ensured information about patients’ wishes was highlighted in their health records so colleagues and other services could clearly see this.