The Pines 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 that staff involved people in decisions about their care and treatment and provided them with advice and support. People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people to ensure they took decisions in people’s best interests where they did not have capacity. There was evidence of effective systems to monitor and support patients with long term conditions. This key question has been rated as good.

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 practice 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 was predominantly positive. Results of the national GP patient survey (published in July 2025) showed 88% of patients felt their needs were met during their last GP appointment compared to the national average of 90%. 94% of patients felt the healthcare professional they saw had all the information they needed about them during their last appointment compared to the national average of 92%. Leaders and staff told us the practice used codes and alerts on the patient’s record to highlight special needs and requirements. 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 had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The practice planned and delivered people’s care and treatment with them, including what was important and mattered to them. Meetings were held to ensure staff were updated with the latest information, guidance and changes within the practice.  

The clinical searches we undertook of the practice’s clinical records system showed the monitoring of people with long-term conditions was in line with National Institute for Health and Care Excellence (NICE) recommendations. For example, one of our clinical record searches reviewed patients with chronic kidney disease (CKD) stages 4 or 5 to check they had the appropriate monitoring was being undertaken. We found all patients were receiving appropriate monitoring.

We reviewed the number of patients with asthma who had been prescribed two or more courses of rescue steroids in the last 12 months. We identified a total of 30 patients and reviewed a random sample of 5 patient records. We found that 1 patient had received 2 courses of rescue steroids, although they had received a follow up following the first course, they had not received a follow up to the second course. All other patients had received appropriate follow ups.

We reviewed monitoring of people with hypothyroidism (when the thyroid gland does not produce enough thyroid hormone that can lead to tiredness and weight gain). Our search identified 457 patients, all of whom had received appropriate monitoring in the preceding 18 months.

We reviewed the monitoring of diabetes care and found that 84 patients appeared to have not been reviewed despite having HbA1C levels of 75mmol or more. (HbA1C is a blood test that measures the average blood glucose levels over a period of 2 to 3 months). We reviewed a random sample of 5 patients and found no concerns with the management of their care.

The practice held registers for patients and provided annual health checks for those with learning disabilities, people with severe mental health conditions and palliative patients.

The practice shared evidence of clinical audits undertaken to effectively improve patient care. For example, the practice shared an audit undertaken to assess whether patients receiving an IUD/IUS in the practice receive care that meets NICE and Faculty of Sexual Reproductive Healthcare (FSRH) standards. Results demonstrated 100% compliance with the standards.

The practice 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 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. The processes in place enabled staff to liaise regularly with community teams such as district nurses, health visitors, and palliative care nurses. Staff told us and we saw evidence of regular multi-disciplinary team meetings that were held with external agencies where vulnerable people were discussed and actions were recorded. The practice regularly discussed patients receiving end-of-life care.

The practice supported patients living in 4 local residential care homes. There was a dedicated GP lead and a dedicated care coordinator who acted as a key point of contact for the services to ensure they received timely support. Feedback received from leaders at some of these services was extremely positive. They described consistently good care, efficient communication and improved coordination of care for care home residents. They reflected positively on the benefits of regular ward rounds, continuity of care and said that their concerns were always listened to.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff were consistent in supporting people to live healthier lives through a targeted and proactive approach to health promotion and prevention of ill health, and every contact with people was used to do so. Staff focused on identifying risks to people’s health, including those who are (or might be) vulnerable such as 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 practice had introduced the use of Asthma Control Test (ACT) reviews for asthma patients before their nurse appointment. (ACT reviews are a quick evidenced-based way to check how well asthma is being managed in daily life). Leaders advised this allowed for more structured conversations and health management planning whilst reducing appointment times by ensuring the nurses had as much information as possible available in advance of the appointment. In addition, they advised that patients who were previously considered poor attenders had been more responsive to the ACT questionnaire.

Leaders advised of plans to recommence group patient education sessions for prediabetes. These sessions had enabled groups of 10 to 12 patients to attend the practice and receive practical support with managing their health.

The practice 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.

At the time of our assessment, the latest published information from the UK Health Security Agency (UKHSA) showed that the practice had exceeded the World Health Organisation (WHO) expected target of 95% for the number of children aged 2 immunised against various infectious childhood diseases for all age groups. For children aged 5 the practice achievement was just short of the WHO minimum target of 90% with a practice achievement score of 89%. We saw the practice provided children’s packs to all children attending for immunisations. These packs were used as a reward and also to encourage positive association between the GP service, vaccinations and the child, they contained engaging and fun activities for children.

The latest published information available to the CQC from NHS Digital (June 2024) showed the practice’s uptake for cervical cancer screening for women aged 25 to 49 years old was slightly below the 80% national target, observed at 77.6%. The practice’s uptake for cervical cancer screening for women aged 50 to 64 years old was also below the 80% national target, observed as 76.8%. Leaders advised they had undertaken targeted work to improve cervical cancer screening uptake. This included the provision of additional Saturday clinics outside of the practice’s core hours which would be organised as needed to support patients unable to attend during normal practice hours. They were able to share unverified data for the period ending March 2026. This showed the practice’s uptake for cervical cancer screening for women aged 25 to 49 years old was 83.1%. The practice’s uptake for cervical cancer screening for women aged 50 to 64 years old was 85.6%.

In May 2026, the practice undertook a colon cancer audit, aiming to improve the level of bowel screening uptake benchmark practice performance and ensure opportunities for early cancer diagnosis were maximized. The audit compared practice data from July 2022 against data from May 2026 to ascertain whether specific actions, for example, the follow up of bowel screening non- responders had been actioned. The audit found that the number of non-responders had declined slightly from 32% to 27%. It also highlighted that practice systems to offer further support and encourage uptake were well embedded and running efficiently. The practice planned to undertake a similar audit for breast cancer screening.

The practice told people about their rights around consent and respected these when delivering person-centred care and treatment. People we spoke with and the evidence we reviewed did not raise any concerns around consent. People understood their rights about consent to the care and treatment they were offered. Clinicians understood the requirements of legislation and guidance when considering consent. Clinicians supported people to make decisions ensuring their views and wishes were considered during care planning. Assessments of mental capacity were carried out when needed and were decision specific. 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. 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 informed consent, the 2005 Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS); 2 members of staff were slightly overdue their refresher training. We saw that consent was documented and processes were in place for chaperones to be present if requested.

In line with locality requirements, the practice was transitioning from the use of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions to Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms. Records we reviewed demonstrated these were appropriate, regularly reviewed, and made in line with current legislation and professional standards.