Cheriton Bishop & Teign Valley 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.

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 was positive. People felt involved in assessment of their needs and felt confident that staff understood their individual and cultural needs.

Reception staff were aware of the needs of the local community. They used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present.

The service worked in partnership with a local community based charity. The service provided office space to the charity, and they worked collaboratively to support people with social needs through a memory café, lunch clubs, supermarket trips, transport to medical appointments and prescription delivery within the rural area.

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.

Information to support and raise awareness among carers was available both on a noticeboard in the waiting area and on the service’s website. The service had a designated carers champion who maintained a register of people identified as carers and supported them, arranged carers’ health checks and signposted them to community services.

Our remote clinical searches found the service had effective systems to identify people with previously undiagnosed diabetes.

People with long-term conditions, including chronic kidney disease stage 4 or 5 (more advanced stages) or an underactive thyroid, received necessary monitoring.

People diagnosed with diabetes who had a HbA1c of 75mmol/mol or above received appropriate care and treatment. (A high average HbA1c blood sugar level indicates poor diabetic control with increased risk of complications.)

People with acute exacerbations of asthma (worsening or significant increase in symptoms) received appropriate follow-up and review.

The service 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 had access to relevant national guidance, as well as local policies and guidelines and used this information to help ensure that people's needs were met. Clinical records demonstrated care was provided in line with current guidance.

The service monitored its antibiotic prescribing data to ensure it is based on evidence-based guidelines and antibiotics were only prescribed when truly necessary. NHS Data showed their prescribing of various types of antibiotics was all lower than national averages.

Our remote clinical searches found people on medicines that required monitoring were effectively reviewed. For example, people prescribed disease-modifying anti-rheumatic drugs (DMARDs) (DMARDs are medicines to reduce inflammation and prevent permanent joint damage).

However, the clinical search identified 76 people prescribed a nonsteroidal anti-inflammatory drug (medicines used to reduce pain, fever, and inflammation) in people aged over 65 years or anti-platelet drug (medicines that prevent blood clots) in people aged over 75 years. Both medicines increased the risk of digestive tract bleeding. We sampled and reviewed 5 records and found 3 of them would benefit from proton pump inhibitor prescription (medicines that protect the digestive tract from bleeding). Following the clinical searches, the service contacted and reviewed all the patients in this category within 2 weeks post-inspection.

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.

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. We received various positive feedback comments from people who use the service about timely and efficient referrals to other services for ongoing care. One person commented, “I was impressed by both the speed of the response and to be able to get an immediate appointment and then a rapid onward referral and the quality and thoroughness of the aftercare.”

When vulnerable people transferred to another GP service, staff attended multidisciplinary team meetings to share knowledge about the people with the new service to promote a smooth transition of care.

The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

The service identified people who may need extra support and directed them to relevant services. This included people in the last 12 months of their lives, people 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 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.

Latest national data from the NHS England (2024) showed the service met the national targets for cervical screening of 80%.

National data (2024-2025) showed the service had achieved the 90% minimum uptake for 2 out of the 5 indicators for childhood immunisations. The other 3 indicators were all at 87%. The service was aware of the findings and took part in a quality improvement project to address this. For example, the staff contacted outstanding people by text, telephone and letter and followed up missed appointments to rebook or arrange another appointment to discuss any concerns about vaccination. The service also offered an online booking option for vaccination appointments and sent text reminders for all appointments. Unverified data at the time of assessment showed 4 of the indicators had achieved the 90% minimum uptake with 3 of them above the 95% target recommended by the World Health Organization (WHO) and the remaining one was at 85%.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Clinicians understood the requirements of legislation and guidance when considering consent and decision making. Clinicians supported people to make decisions. Where appropriate, they assessed and recorded people’s mental capacity to make a decision.