Great Ayton Health Centre

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 any assessment of their needs and felt confident that staff understood their individual and cultural needs.

The National GP Patient Survey results showed that 97% of patients felt that the healthcare professional they saw had all the information they needed about them during their last GP appointment. This was above the local and national averages of 92%.

99% of patients stated that they had confidence and trust in the healthcare professional they saw or spoke to during their last GP appointment. This was also above the local and national averages of 93%.

Reception staff were aware of the needs of the local community and used digital flags within the care records system to highlight any specific individual needs. 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 provider 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 service mostly 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.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation.

As part of our assessment, a series of patient clinical records searches were completed by a CQC GP specialist advisor. The search criteria used is freely available for practices to access at any time. The records of patients with long-term conditions were reviewed to ensure that the required monitoring was taking place.

Our searches included a search for patients with asthma who had had two or more courses of rescue steroids in the last 12 months (excluding patients who had been prescribed regular steroids for other purposes). Management of their condition appeared to be good with adequate assessments undertaken at the time of prescribing and appropriate follow-ups to check patients’ response to treatment.

Our searches also included searches in relation to the monitoring of patients with chronic kidney disease (CKD) stages 4 and 5; patients with hypothyroidism; and patients with diabetes who's latest HbA1c was > 75mmol/l. Although none of these searches identified any potential patient harm, one patient with CKD was identified as requiring a urine and electrolyte test; one patient with hypothyroidism was identified as requiring a blood test; and two patients with diabetes were noted as having raised blood pressure and required a review.

The practice immediately followed up on these findings.

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.

Leaders and staff were working with their local primary care network (PCN) to meet the needs of the patient population. For example, over the last 12 months, the practice had engaged in a programme of clinical educational meetings with their neighbouring practice with topics discussed including monthly national clinical guidelines and clinical knowledge summaries, clinical case reviews, a review of new cancer diagnoses and audits.

The service supported people to manage their health and wellbeing to maximise their independence, choice, and control. The service 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.

For example, as part of our series of patient clinical record searches, a search was completed on patients having a potential missed diagnosis of diabetes. Whilst one patient was identified as having a potential missed diagnosis of diabetes, this had only recently been diagnosed and coded. The systems to identify these patients and make sure they were offered the appropriate investigation, treatment and monitoring were mostly effective.

Staff supported national priorities and initiatives to improve population health, including smoking cessation, diabetes and tackling obesity. The Frailty Nurse also worked to identify frail patients who may benefit from personalised care and social prescribing.

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.

Clinical and non-clinical audits were carried out to improve outcomes for patients. These included audits on skin cancer referrals, palliative care, gout management, and glucose self-monitoring and an audit of steroid injections given by the physiotherapist.

The practice met the national target of 80% for screening of cervical cancer in 50 to 64-year-old women and was just below target for the 25 to 49-year-old age group at 78%. They also exceeded the World Health Organisation national targets for all childhood immunisations and would follow up on those patients who did not attend their appointments for health checks to ensure they received the necessary care.

Patients with a learning disability were offered an annual health check. Local monitoring arrangements for ensuring the checks were offered were in place. At the beginning of August 2025, the practice had completed 80% of checks with the other four patients declining a review.

NHS health checks were offered to patients opportunistically as part of locally agreed contracts. Unverified data provided by the provider showed that in the last 12 months 1755 patients had been invited for an NHS health check and 222 checks had been completed.

The practice did not routinely offer health checks for patients over the age of 75, however if a patient requested a health check they would be offered a well man or well woman check.

From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

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. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.

Audits had recently been completed for one medical procedure to ensure consent was being appropriately recorded in the patients’ records.