Gough Walk Practice

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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

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support and staff regularly reviewed people’s care and worked with other services to achieve this. We found the effectiveness of people’s care, treatment and support did not always achieve good outcomes. Some patients had not received care in line with best practice guidance. This is the first assessment for this service since its registration with CQC. This key question has been rated as Requires improvement.

This service scored 58 (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 did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them. Some patients had not received care in line with recommendations and best practice guidance.

As part of the assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. A sample of the records of patients with long-term health conditions were checked to ensure the required monitoring was taking place. These searches were visible to the service.

Our clinical search identified a total of 17 patients with asthma who have been prescribed 2 or more courses of rescue steroids in the last 12 months. We checked 4 of these patients records in more detail and found concerns with the management of 3 patients following acute exacerbation of asthma. We found staff were not using standardised codes on the patient records system to record annual asthma reviews.We raised this with leaders who told us the practice used local asthma monitoring codes as agreed with the NEL ICB, and performance was measured against those codes. In addition, patients steroid cards were not in place for some patients. The service told us they would review and respond to these findings to ensure patient safety. This included adding standard read codes for annual asthma reviews to patient records and ensuring all automatic and repeat prednisolone prescriptions were not issued acutely without a clinical review. Steroid cards would also be issued for relevant patients.

CQC clinical searches identified 22 patients with an underactive thyroid who had not received appropriate thyroid function test (TFT) monitoring. We reviewed 2 patient records and found both patients with hypothyroidism were significantly overdue thyroid function test monitoring. There was no record that monitoring had been checked prior to issuing the last prescription. Following our feedback, the provider told us they will run a search of hypothyroid patients and ensure they are recalled every 12-18 months.

A search identified 191 patients with a complication of diabetes with poorly controlled blood sugar. We looked at 4 records and issues were identified with the management and monitoring of all 4 patients. Patients had not been reviewed and followed up in line with national guidance. We raised these concerns with the provider who told us they had taken immediate action to contact these patients. Leaders told us engagement can be difficult with some diabetes patients.Following our assessment, leaders told us the practice had exceeded the target for the 3 NICE treatment targets to prevent diabetes complications in patients with type 2 diabetes (triple target). The service achievement for retinal screening uptake reached 80%, exceeding the local target of 75%.

All patients who presented with urgent needs, were triaged by a clinician to provide early assessment and to help prevent admission to secondary care. 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. We reviewed a sample of learning disability and mental health patients’ annual care plans and found they were satisfactory.

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. 723 surveys were sent out, and 109 surveys were received (15% completion rate). Of those who responded, 87% of respondents felt their needs were met during their last general practice appointment.

The service used an electronic patient support platform to support the delivery of evidence-based care and had integrated national guidance and local medicine optimisation pathways to support medicines monitoring. Staff shared performance data from the North East London ICB integrated care dashboard which indicated that Gough Walk Practice achieved the second-highest level of compliance in Tower Hamlets and was part of the highest-performing PCN in the borough. However, the clinical searches found patients’ needs were not always assessed, and care was not always delivered in line with legislation and clinical standards, supported by pathways and tools. For example, information had not always been placed on patient records to ensure that it was safe to continue to prescribe and that the patient received appropriate care and treatment.

The service took part in local incentive schemes for chronic obstructive pulmonary disease, asthma, and diabetes to improve patients’ health outcomes. The service used a spreadsheet to ensure patients were recalled for their annual health reviews.

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. Leaders shared evidence of transfer of care documents for certain medicines which were initiated in secondary care which aimed to provide sufficient information to ensure that it is continued safely and monitored appropriately in primary care. There were systems in place to support the effective assessment and treatment of patients with more complex needs. For example, clinicians attended monthly Integrated care meetings to provide coordinated care for patients with complex needs.

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 manage their health and wellbeing. They focused on prevention and early intervention to help reduce future care needs. Staff identified health risks such as end-of-life needs, frailty, carer responsibilities and supported national health priorities, including smoking cessation and obesity reduction. Staff told us patients had access to a community mental health specialist nurse. Leaders reported that the primary care network (PCN) was working across Tower Hamlets communities to reduce health inequalities and promote preventative healthcare.

The provider had processes to monitor people’s care and treatment to continuously improve it. However, they did not always ensure outcomes were positive and consistent or met both clinical expectations and the expectations of people themselves.

Although there was a system in place to recall patients for long term health condition reviews, processes for reviewing the uptake of patient monitoring needed strengthening. Results from our clinical searches showed there were some shortfalls in ensuring relevant blood tests had been carried out prior to a review or prescriptions being issued.

The provider submitted clinical audits which they had carried out to improve outcomes for patients. Findings from audits were shared with staff to help identify further areas for improvement in outcomes for patients.

The service had not met the WHO based national target of 95% for five of the childhood immunisation uptake indicators (01 April 2023 to 31 March 2024). The practice was in an area of high deprivation and understood the challenges of engaging with under-represented groups in the community. The service had a call and recall protocol and 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 practice had the highest achievement in the PCN for the percentage of children aged 1 who have completed a primary course of immunisation.

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 both younger patients (aged 25 to 49 years) and older patients (aged 50 to 64 years). However, the service provided unverified data for 2025 to demonstrate achievement against the national targets for both cohorts had improved. For example, data from 1 April 2024 to 31 March 2025 indicated 80.8% coverage for women aged 25 to 49 and 83% coverage for women aged 50 to 64.

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.