Valley View 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

Staff had access to training and learning opportunities to support them in their role. The practice engaged with other services and supported patients to manage their health and wellbeing. Despite some efforts from the practice, cervical screening and child immunisations uptake rates were below national targets. Processes were in place to support patients to make informed decisions about their future, and to review patients at the end of their lives.

This key question has been rated as Good.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A review of clinical records showed that the treatment of patients with some long-term conditions including chronic kidney disease was effectively managed. However, we also found the following:

There were 546 patients on the practice’s asthma register, of which 26 had been prescribed 2 or more courses of rescue steroids. We reviewed records for 3 of these patients and found that they had been adequately safety netted, however their medication reviews sometimes contained limited information, and none had been issued with a steroid emergency card. After the assessment the practice told us it had reviewed records for all 26 patients and had taken action, which included contacting the patients for review and issuing steroid cards where indicated.

There were 5 patients diagnosed with hypothyroidism who had not had the required monitoring in the last 18 months. Of these patients, 3 were being monitored by paediatrics specialists. We reviewed the remaining 2 records and found that the practice had made some efforts to contact the patients. After the assessment the practice told us it had made further attempts to book these patients in for blood tests.

There were 184 patients registered with diabetes and with a latest HbA1c of more than 74mmol/l. We reviewed records for 3 of these patients and found that monitoring was either overdue or that reviews contained limited information. It was however noted that some patients had poor compliance with medications and with requests to attend for monitoring appointments. The practice told us that it was continuously looking at ways to improve patient engagement and compliance, such as referral to BEEP (Bradford Encouraging Exercise in People), a service that encouragespeople to become more active. After the assessment the practice told us it would review records for all patients in this category and run additional diabetes clinics to follow up these patients appropriately. Furthermore, the practice told us it had acknowledged that some medication reviews lacked sufficient detail and that this has been discussed with the practice’s pharmacist team.

The practice had a palliative care register with 13 patients, and these patients were reviewed in monthly multidisciplinary meetings.

Patient’s accessibility and communication needs were taken into account, and they were supported accordingly, for example through the use of interpretation and translation services. Staff could refer patients with specific needs, such as those experiencing poor mental health, to social prescribers and other services.

There was a clinical triage process in place, and staff had received training in care navigation.

Clinical staff told us they followed best practice guidance when carrying out their work. They also told us they had access to training and learning opportunities and were supported with their professional development.

However, as part of our clinical searches we reviewed records for 5 patients prescribed methotrexate (a disease-modifying anti-rheumatic drug) and found all 5 records did not specify the day of the week the medication was to be taken, in line with Medicines and Healthcare products Regulatory Agency (MHRA) guidance. After the assessment the practice told us it would take action to address this.

Staff had access to the information they needed to appropriately assess, plan, and deliver patient’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. Staff and leaders told us how they managed information sharing with other providers, including out of hours team. We saw that there was continued engagement with members of the primary care network.

The practice supported patients to manage their health and wellbeing to maximise their independence, choice and control. Patients were supported to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported initiatives to improve population health. This included referral to social prescribers and for mental health support, as well as encouraging patients to attend for cancer screening.

There were processes in place to invite patients for relevant health checks. In the last 12 months 100 NHS health checks had been completed. There were also systems in place to identify patients in need of extra support, for example those with a learning disability. The practice had 47 patients on their learning disability register, and all 47 had received a health check in the last 12 months. Information to support patients was available around the practice and on the practice website.

The GP Patient Survey for 2025 showed that 44% of patients felt they had enough support from local services or organisations to manage their long-term conditions or illnesses, compared to the national average of 69%.

The practice’s cervical screening uptake rate in June 2024 was 56% for patients aged 25 to 49 years old, and 75% for patients aged 50 to 64 years old, which were both below the 80% national target.

Data from March 2024 showed that the practice had not met the 90% minimum uptake rate for all 5 routine childhood vaccinations indicators, and that 4 out of 5 of these were below 80%.

The practice told us of the steps it took to encourage patients to attend for cervical screening and childhood immunisations, which included phone call follow-ups of non-attenders, discussion and education, and carrying out opportunistic testing. In addition, the practice had a breast screening champion.

Staff we spoke with could outline the systems in place to recall and review patients and understood their role in this process.

Appropriate registers were held to ensure effective monitoring of specific groups such as those receiving palliative care.

Staff told us how they dealt with consent and how they helped patients make decisions about their care, including the use of relevant guidelines and recording consent.

There was a consent policy in place which covered areas such as capacity and Deprivation of Liberty Safeguards. Processes were in place to support patients to make informed decisions about their future, and to review patients at the end of their lives. Staff also told us how they worked with patients, and their carers, to support them to understand their options regarding Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions. We reviewed 5 patient records and saw that DNACPR and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms were completed in line with guidance and with the input of patients, and when necessary, their carers.