Keele 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

This is the first inspection for this service since its registration with CQC with the provider North Staffordshire Combined Healthcare NHS Trust. This key question has been rated as Good.

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. The service had effective systems for identifying and monitoring patients with long-term conditions. Patients were appropriately reviewed, recalled and managed. The practice used population health data and clinical audit activity to understand and respond to the needs of its population, including targeted initiatives to improve cervical screening uptake and access to care for its university student population.

Personalised care was supported through longer appointments where required, reasonable adjustment processes, proactive identification of undiagnosed conditions, regular health reviews and appropriate referral pathways. Staff had the skills, training and resources needed to deliver effective care, including annual health checks for patients with a learning disability and ongoing reviews for housebound patients to promote equitable access to services.

The practice achieved positive childhood immunisations and shingles vaccination uptakes, with care delivered in line with evidence-based guidance. Where cervical screening uptake was below target, the practice implemented a targeted improvement strategy that resulted in a measurable increase in uptake and demonstrated a proactive approach to reducing health inequalities and improving access to preventive care.

Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Most of the 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. Reception staff were aware of the needs of the local community. Reception staff 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. 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. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The provider had effective systems to identify people with previously undiagnosed conditions. There were 6 patients identified by our clinical searches as having the potential for a missed diagnosis of diabetes. We reviewed 5 of the 6 and found these to be satisfactory.

Our clinical searches found of the total number of patients with diabetes and a high blood sugar monitoring result (HbA1c >75mmol/l) was 17 out of 141 patients. We sampled 5 of the 17 records and found these to be satisfactorily monitored and reviewed. One of the 5 patients had potentially left the area.

Of the 118 patients with hypothyroidism our clinical searches identified 3 patients with the potential not to have been in receipt of thyroid function test monitoring for 18 months. We reviewed the 3 records and found these patients had been identified and invited for monitoring but were unresponsive to the practice recalls.

We reviewed the records of the 3 patients out of the 10 our clinical searches identified with chronic kidney disease at stage 4 or 5, who had the potential to have

not had blood test monitoring in the last 9 months. We found these to be satisfactorily monitored and reviewed in secondary and community care settings.

Our clinical searches found of the 630 asthma patients that 6 had been prescribed 2 or more courses of rescue steroids. We reviewed these records and found patients were followed up in exacerbation, were prescribed an inhaled corticosteroid and fully reviewed. Two patients were prescribed steroids for other conditions than asthma and had been recalled but had yet to respond.

Care plans and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) records were completed and reviewed regularly to ensure they remained accurate and reflected patients’ current needs and wishes. The provider had effective systems in place to identify patients with previously undiagnosed conditions and to facilitate timely intervention. Systems were also established to identify patients with caring responsibilities, who were offered an annual review to help support their health and wellbeing needs.

The practice demonstrated an understanding of the needs of its registered population and used this information to plan and deliver services effectively. This included responding to the fluctuating demand associated with a large university student population, with significant numbers of students registering and leaving the practice at key points during the academic year, alongside meeting the ongoing healthcare needs of their wider local population. The provider considered these differing population needs when designing and delivering services to support timely access to care and treatment. For example, clinical audits were undertaken to explore cervical screening and vaccination uptake. The aim was to increase cervical screening engagement among patients overdue by more than 6 months by identifying barriers and improving booking rates. The findings identified that some students received these services through their home GP practice rather than the university practice, creating additional complexity in monitoring uptake and collecting accurate data. The recommendations included ensuring smear records completed elsewhere were appropriately coded and considering protected appointment slots when conducting targeted screening outreach. Of, all patients contacted, 66.3% were successfully reached. Among those reached, 39.2% agreed to an appointment and 24.2% completed a booking, resulting in an overall booking rate of 16.0% across the total patient cohort. In response to the audit findings, the practice implemented the recommendations to enhance access to screening, including improvements to appointment booking processes and appointment availability to better meet students’ needs. Early indications indicated these changes had been well received and have had a positive impact on screening uptake.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Staff had access to both local and national guidelines through easily accessible online platforms, with direct links also embedded within the clinical system. Updates to guidance were shared through meetings and learning events, and clinical audits were undertaken to ensure care remained aligned with legislation and recommended practice. Clinical records we saw demonstrated care was provided in line with current guidance. For example, the clinical search records we reviewed for people who received treatment following an exacerbation of their asthma demonstrated they were followed up within 48 hours, recalled if they did not respond and had evidence of safety netting advice.

Standard appointments were all 15 minutes and patients with complex health needs were given longer appointments to review their 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.

Systems, such as reasonable adjustment digital flags were in place to further support personalised care.

All patients with a learning disability were invited to attend an annual health assessment. Practice data showed that all had received a review within the previous 12 months. The practice also carried out reviews for patients with long-term conditions who were housebound, helping to ensure equitable access to ongoing care and monitoring.

Appropriate referral pathways were in place to support the timely assessment and management of patients’ needs. Staff demonstrated they had the skills, knowledge and training required to undertake reviews and assessments relevant to their roles, ensuring patients received care and support that met their needs.

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. Referrals to other services were

monitored to ensure that appointments were booked for patients in a timely manner, for example, when patients were referred for suspected cancers.

We found evidence of a well-established meeting structure across the service, providing comprehensive governance and assurance arrangements. The meetings supported clinical oversight, governance, quality assurance, safeguarding, performance management and operational delivery. Regular meetings included clinical, nursing and non-clinical forums, alongside safeguarding, governance, quality and safety meetings. Governance arrangements were supported through a quarterly Committee in Common, monthly Quality Committee, monthly Clinical Effectiveness Meeting, weekly Clinical Professional Advisory Group and monthly Quality Assurance Group. Operational and workforce oversight was maintained through monthly ARRs and Talking Therapies meetings, monthly senior corporate and operational team meetings, performance reviews, senior leadership meetings and risk reviews. Additional Roles Reimbursement Scheme (ARRS) provides additional staff across GP practices and Primary Care Networks (PCNs). The ARRs team for example included clinical pharmacists, physiotherapy services, and a mental health practitioner for children and young people up to the age of 25 and an adult practitioner for people aged 25 years plus.

These reporting arrangements fed into the monthly Directorate meeting and weekly Situation Report (SitRep) meetings, providing clear lines of accountability, escalation and reporting processes and organisational oversight.

Meetings included those with the Trust, the PCNs, community teams, safeguarding, palliative care, talking therapies, the Patient Participation Group, the University as well as other stakeholders such as research and development teams and the Integrated Care Board. Regular multi-disciplinary team (MDT) meetings were held to review areas such as diabetes, respiratory, end of life care and frailty. The practice maintained a direct safeguarding and mental health link with the University Student Support and Wellbeing Teams to provide a dual-layered safety net for vulnerable students.

These arrangements provided a structured forum for staff engagement, enabling all team members to contribute their views. They also supported the communication of the practice’s vision and strategic objectives, while facilitating ongoing staff training and professional development.

The practice demonstrated an effective approach to partnership working underpinned by strong clinical and strategic collaboration. This included active participation in joint multidisciplinary team (MDT) meetings, shared management of patients with complex needs, and consistent, high-quality communication between primary and secondary care clinicians to support continuity and safety of care.

Furthermore, the practice played a proactive and influential role within the Integrated Care Board (ICB), contributing to the development and delivery of system-wide programmes. Its involvement spanned key strategic priorities, including digitaltransformation, tackling health inequalities, workforce development, and improving patient access, demonstrating a clear commitment to system leadership and continuous improvement in patient outcomes.

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 supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

Staff actively signposted patients to local services offering information, education, and tailored advice to support individual needs. Patients were encouraged to engage in national health initiatives, such as cancer screening programmes and childhood immunisations.

The practice has also strengthened support for vulnerable patients by working in partnership with a dedicated social prescriber.

A digitally enabled prevention model pilot was launched in November 2024 to address fuel poverty, cold homes, and health inequalities, with the overarching aim of reducing the incidence of cold-related illness. The programme was delivered through a partnership between North Staffordshire Combined Healthcare NHS Trust, Staffordshire and Stoke-on-Trent Integrated Care Board (ICB), University Hospitals of North Midlands, Graphnet (a supplier of shared care record and population health software), and the independent charity Beat the Cold.

The pilot implemented a programme of targeted interventions designed to support vulnerable patient groups. In total, 894 interventions were delivered, comprising 814 telephone consultations and 80 home visits, supporting 684 patients. Following intervention, 65% of participants (447 patients) reported an improvement in their wellbeing.

The programme also delivered wider social and financial benefits, including 268 Priority Services Register registrations to help protect vulnerable residents during power outages and service disruptions, and 261 referrals for water tariff support to reduce financial hardship and strengthen household resilience. Through direct financial assistance, tariff support, and broader social value initiatives, the programme secured an estimated £356,274 in potential savings and grants for residents.

Overall, the programme demonstrated positive impacts for both individuals and the wider health and care system, highlighting the value of preventative, data-driven approaches to reducing health inequalities and supporting vulnerable populations.

The programme demonstrated positive health system impacts such as:

• A 7% reduction in Children and Young People's (CYP) GP appointments compared with Winter 2024/25, suggesting that earlier intervention helped prevent avoidable deterioration in health.
• Improved asthma management contributed to a 15% reduction in CYP inhaler use across two winter periods, indicating better symptom control and a reduced reliance on reliever medication.
• Preventative support and medication reviews generated an estimated £60 saving per review and prescription, alongside improved health outcomes for patients.

The practice met national targets for childhood immunisations. 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.

For the period 01/04/2024 to 31/03/2025 the percentage of children aged 5 who have received immunisation for measles, mumps and rubella (two doses of MMR) 84.4% of the 95% target. This statistic related to 5 children who did not attend. Of the 4 remaining childhood immunisation indicators, 3 had met the 90% minimum, and 1 had exceeded the 95% World Health Organisation (WHO) target.

NHS England data from 2024 showed that 85% of patients, aged 80 years had been in receipt of a shingles vaccine between the ages of 70 and 79 years.

Cervical screening uptake NHS England data from 30/06/2024 showed that the cervical screening uptake of the eligible female population aged 25 to 49 years old was 55% of the 80% target. The cervical screening uptake NHS England data from 30/06/2024 showed that the cervical screening uptake of the eligible female population aged 50 to 64 years old was 74.3% of the 80% target. The practice had a robust strategy to improve uptake where able. This included:

• A focused clinical audit was completed to understand the barriers to accessing the screening offer and use of the recommendations to improve uptake.
• Ensuring smear records completed elsewhere were appropriately coded and considering protected appointment slots when conducting targeted screening outreach.
• A strengthened proactive recall system
• Making every contact count approach with opportunistic screening opportunities.
• Primary Care Network level monitoring and benchmarking
• The development of a reception call script to understand barriers.
• Health awareness topics within the practice and on their website.
• Patient Participation Group waiting room noticeboard to highlight this screening.

Following the audit and implementation of the recommendations, the service achieved a 16% increase in screening uptake.We found the practice actively monitored screening outcomes, including attendance rates, routine recalls, and declines. In addition, it delivered awareness initiatives using accessible resources to address common barriers such as fear and misinformation, supporting patients to make informed choices rather than relying solely on recall systems alone. This proactive approach had resulted in measurable improvement.

Practice staff had access to number of designated leads with specialist knowledge, including roles for carers, cancer, learning disabilities, veterans, patient safety, palliative and end of life ensuring a coordinated and informed approach to patient care and engagement.

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. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

There were registers held for those patients who were vulnerable who were on the palliative care register or at the end of their life. We found that clinicians understood the requirements of legislation and guidance when considering consent and decision making and saw that consent was documented.

There were systems in place to ensure staff kept up to date in training relating to the Mental Capacity Act and Deprivation of Liberty. We found that staff had completed the required training.