Tredegar Practice

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 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff assessed people’s health, care, wellbeing and communication needs with them. Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. The needs of carers of people using services were also assessed to support their health and wellbeing in their carer roles and help them to provide safe care to the people they support.

Patient experience of the service, as reflected in the 2025 National GP Patient Survey, was in line with or higher than local and national averages. Of those who responded, 89% felt involved in decisions about their care and treatment, compared with 88% across the Integrated Care System (ICS) and 91% nationally. 89% of respondents felt their needs were met during their last general practice appointment compared with ICS average 87% and national average 90%.

In the main, staff followed prescribing protocols and guidance to ensure assessments were up-to-date and people’s care needs were routinely reviewed. At this assessment there were a small number of patients whose care needs were not always met. From our review of patients with long-term health conditions we found 7 out of 147 patients with an underactive thyroid who had not had thyroid function test (TFT) monitoring for 18 months. One patient had not had appropriate follow up when their last two readings confirmed a diagnosis of diabetes. We raised these concerns with the leaders who informed us they had taken immediate action to contact these patients.

Leaders had recently implemented a risk management and care planning register to ensure safe care for patients with complex health needs. Clinicians used a care plan template which they created in discussion with the patient. The care plan was designed to highlight and summarise the issues and risks that the consulting clinician needed to keep in mind. The care plan was flagged in the patient’s clinical record so that other GPs were aware of the patient’s particular risks and to support safe prescribing practice.

The service planned and delivered people’s care and treatment with them, including what was important and what mattered to them. From most of the clinical records we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based guidance.

Staff carried out annual reviews for people with long-term conditions. We reviewed a sample of learning disability and mental health patients’ annual care plans and found they were satisfactory.

The service worked well across teams and services to support people. Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The service worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. There were systems in place to support the effective assessment and treatment of patients with more complex needs. Clinicians attended monthly Integrated care meetings to discuss patients with complex needs. Staff attended twice monthly meetings with the Neighbourhood Mental Health Team (NMHT) providing mental health support to patients in the community and attended meetings with the health visitor after each baby clinic. Leaders told us the service participated in the local Primary Care Network (PCN), where they collaborated on shared service delivery and quality improvement initiatives.

Staff supported people to live healthier lives and where possible, reduce their future needs for care and support. Staff focussed on identifying risks to patients’ health, including 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.

Leaders reported that the PCN was working as one of 8 Tower Hamlets communities to reduce health inequalities and prevent long-term conditions as part of the “Communities Keeping Well” project, partially funded by public health, which invites residents in deprived areas to propose healthy lifestyle initiatives. Successful proposals, chosen via community voting, were supported by the PCN project team. Last year, the practice was actively involved in supporting projects which included women’s football, meal-sharing initiatives, family yoga, a Somali women’s activity group, a knitting group, and creative groups for mothers of children with disabilities.

Staff would refer patients to the PCN social prescriber who contacted patients with complex needs or who were vulnerable to ensure their needs were being met. Staff told us patients had access to a community mental health specialist nurse.

Data from the 2025 National GP patient survey showed that 58% of people felt they received enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses. This was below the local average (61%) and lower than the national average (69%). Eighty per centsaid the healthcare professional they saw or spoke to was good at considering their mental wellbeing during their last general practice appointment. This was higher than the local (71%) and national (74%) averages.

The service routinely monitored people’s care and treatment to continuously improve it. Most people who used the service felt they could make an informed decision about their care and treatment because they had been provided with the information they needed to support them to do so. The National GP Patient Survey results showed that 94% of respondents felt the healthcare professional they saw had all the information they needed about them during their last GP appointment. This was above local and national results. 89% felt involved as much as they wanted to be in decisions about their care and treatment. This was in line with the local (88%) and national averages (91%).

The provider shared evidence of quality improvement activities which they had carried out to improve outcomes for patients. Findings from audits were shared with staff to help identify further areas for improvement.

The service provided evidence of actions taken to improve the uptake of childhood immunisations. This included meeting with the linked Health Visitor to work together on engaging more parents and guardians in the immunisation programme. We saw unverified data which showed improvements in immunisation targets over the last 12 months.

The service told us the PCN provided cervical screening clinics at the local extended access hub. The service had a recall system and sent texts to patients with information about cervical screening and a self-booking link. Data we reviewed showed low performance in the uptake of cervical screening among younger patients (aged 25 to 49 years) However, there were improvements in the uptake of cervical screening in the patient cohort aged 50 to 65 years.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. Staff understood and applied legislation relating to consent. Clinical staff had completed training in the Mental Capacity Act. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.