Thorntree Surgery

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, and that 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 remained as Good.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had systems to identify people with undiagnosed conditions, and staff highlighted their efforts to opportunistically look at the ‘bigger picture’ for patients health during appointments.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber, and the practice had close links with this service.

People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. The percentage of respondents to the latest national GP patient survey who stated that during their last appointment they were involved as much as they wanted to be in decisions about their care and treatment was 89%, in line with the local average of 92% and the national average of 91%.

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.

Relevant information was routinely shared with other professionals when planning care and treatment, and patient records were updated promptly to reflect any changes. The provider had effective systems in place to identify patients with potentially undiagnosed conditions, such as diabetes or cancer. Clinically vulnerable individuals were prioritised, and the practice worked closely with other healthcare professionals to deliver well-coordinated care. Systems for review and recall worked well. In the latest GP Patient Survey, 76% of respondents said they had enough support from local services or organisations to help manage their long-term conditions or illnesses, slightly above the local average of 72% and the national average of 69%.

Those living with long-term conditions or learning disabilities were invited for regular reviews, by a variety of means including individual follow up phone calls for non-responders. While our clinical searches found a very small minority of patients overdue for some tests, we could see the practice had made attempts to contact these patients.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation, which included peer reviews, appraisals, regular clinical training reviews, time-out sessions, and access to training and development to enable them to feel confident in their roles.

A remote review of the patient record system showed that patients received appropriate long-term condition reviews. We saw that where tests were needed, the practice took reasonable steps to try and encourage patients to attend the practice for these.

For patients with the most complex needs, the GPs worked with other health and care professionals to deliver a coordinated package of care.

The provider 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 practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. Staff highlighted good communication within the practice.

The provider worked closely with their Primary Care Network (PCN) and local care homes, with an Advanced Nurse Practitioner employed by the PCN conducting 'ward rounds' on a weekly basis.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. 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 proactively supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. Clinicians opportunistically discussed health promotion and social prescribing during appointments, and opportunistically looked to book cervical screening appointments where possible.

The practice were behind expected rates for completion of NHS Health Checks for adults. From April 2024-March 2025, 525 patients were eligible for an NHS Health Check. 89 patients were invited for the check with 16 patients attending for the full NHS Health Check. From April 2025-March 2026, 510 patients were eligible for an NHS Health Check, with so far 60 patients being invited. All eligible patients should be offered a check every 5 years.

The practice were working with the local GP federation to organise pop up clinics in the area to carry out these checks, however had not yet managed to confirm dates for these. The checks were promoted within the practice, and staff opportunistically invited eligible patients.

The practice had completed a pilot in which an Individual Placement Support Employment Specialist worked directly with patients with Severe Mental Illness to provide support to help achieve paid employment. This pilot had received positive patient feedback, and had now been widened across the area.

The provider routinely monitored people’s care and treatment, and had good processes in place to monitor results and referrals, but struggled to engage with their practice population for proactive health planning. There were lower completion rates of bowel and breast cancer screenings when compared to the national average. The practice was below minimum uptake target rates for all childhood immunisations.

The practice was below both cervical screening indicators (for younger and older populations) at 58.8% and 59.5%, significantly below the national target for both of 80%.

The practice invited patients routinely and opportunistically to Cervical Screening and proactively called patients who were overdue for screening tests. Patients could book via text links, online, or in response to letter invites and telephone calls. Screening tests were promoted within the practice using notice boards. The practice offered a range of appointments to patients as well as Enhanced Access appointments on Saturdays at the provider’s surgery.

The practice had participated in a PCN project with the Northern Cancer Alliance, a multi-agency collaborative of providers, commissioners and charitable organisations, to improve cervical screening rates, and also sought help from the local GP Federation. A new process was implemented using new wording of invitation letters and prompting the 3rd invite to be a proactive call with a trained registered nurse who would contact the patient, discuss the benefits of cervical screening, what to expect and answer any questions and then book patients directly for an appointment. Due to positive patient feedback, the nursing team now had weekly set aside time for these proactive calls, but had so far not managed to increase rates.

The practice had a good understanding of barriers their patients faced in care planning and preventative health care, including digital exclusion and communication difficulties, and tried to work to reduce these.

The practice had a good programme of clinical audit. We saw examples where patient care and outcomes had improved; for instance improvements in antibiotic prescribing practices for female urinary tract infections (UTI’s), and improvements in the review process for patients prescribed Hormone Replacement Therapy ( HRT).

The provider 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 and had received appropriate training. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation with documented discussion. We did identify one coding error for a patient which was rectified.