Healey 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

We assessed all the quality statements in this key question.

We found systems to keep practitioners up to date with current evidence-based practices. There was clear evidence of clinicians’ continued learning, evaluation and supervision.

During this assessment we found clinical staff involved people in decisions about their care and treatment and signposted them to appropriate advice and support. Staff worked with other services to achieve good outcomes.

Patients with long term conditions received reviews that included all elements to sustain good outcomes.

Patients were followed up in a timely manner when necessary, however the clinical searches indicated action was needed to strengthen this process.

Quality improvement activity evidenced changes made for immediate improvement. However, it was not always clear how improvements would be sustained.

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.

Comments from people who used services indicated needs were assessed and care and treatment maximised, however, this was not always communicated in a manner they would like.

Leaders and staff gave examples of how the service maximised meeting the health and care needs through assessing and reviewing care needs.

Methods included personal phone calls to encourage people with specific long- term conditions to attend health checks. Longer appointments were provided for specific reasons. Administration staff could use the specific algorithms to provide patients with an option for a same day referrals to specific specialist services such as the women health unit. or specialist childhood service run by specially trained clinicians.

We found systems to keep practitioners up to date with current evidence-based practices. There was clear evidence of clinicians’ continued learning, evaluation and supervision.

During this assessment we found clinical staff involved people in decisions about their care and treatment and signposted them to appropriate advice and support. Staff worked with other services to achieve good outcomes.

Patients with long term conditions received reviews that included all elements to sustain good outcomes.

Patients were followed up in a timely manner when necessary, however the clinical searches indicated action was needed to strengthen this process.

Quality improvement activity evidenced changes made for immediate improvement. However, it was not always clear how improvements would be sustained.

Feedback about the clinical staff was all positive.

In the main people felt involved in any assessment of their needs and felt confident that clinicians understood their individual and cultural needs. Feedback included comments that the practice was a training practice, so doctors were well supervised and up to date, however, this also meant patients did not see the same clinicians over a period of time.

Patients described care and treatment provided in a timely manner with effective signposting. There were occasions, however where, despite describing good outcomes, patients also expressed concern about communication and lack of empathy from front of house staff.

Staff and leaders were aware of the needs of the local community. Staff told us they checked people’s health, care, and wellbeing needs during health reviews.

Leaders described the action taken to support and encourage hard to reach people to access screening and immunisation services.

The provider had systems and processes to keep clinicians up to date with current evidence-based practice. People’s immediate and ongoing needs were fully assessed. This included their clinical needs and their mental wellbeing.

Staff could add digital flags within the care records system to highlight specific individual needs, such as the requirement for longer appointments or for a translator to be present.

The provider had systems to ensure staff were up to date with national legislation, evidence-based good practice and required standards. For example, the provider had a standing agenda item on the monthly meeting for National Institute for Health and Care Excellence (NICE) updates.

The practice is a teaching practice with responsibility for taking qualified doctors training to be GP’s through the final part of their examinations and assessments before being licensed as GPs.

Various processes were in place for training, evaluation and supervision, which were detailed and all encompassing. The processes were well established and met the expectations of the North Western Deanery and achieved a Gold reward from Manchester Medical School for medical student teaching.



Clinical staff were encouraged to learn about new and innovative approaches and carry out various research and comparative studies to identify how improvements could be made to the service delivered.

Topics covered were part of the 3 year Royal Colleague of General Practice cirriculum. It could be helpful if in addition to the RCGP training cirriculum based projects, the practice also looked at devloping a more targetted research plan based on local needs.

We saw there were sufficient clinical staff in place and evidence they received effective induction, appraisals and clinical supervision. Records indicated that at clinical staff meetings the whole cliinical team discussed and learnt from the clinical issues raised.

People had no specific feedback on this area.

Staff and leaders described action taken to ensure information about people was shared between services including sharing information between services to ensure people receive their preferred end of life care.

Partners indicated the practice used social prescribing effectively and full information was provided when referrals were made to that service.

The practice had processes for ensuring continuity of care included systems for receiving and processing letters and appointments, ensuring flags were placed on peoples records for people of vulnerable people who may need additional support to navigate their was through the care system.

An electronic system has been introduced to manage repeat prescriptions.

Electronic systems in place to ensure extended services had access to relevant information appeared effective and records were updated simultaneously.

We found the process for dealing with tasks including those to ensure continuity of care and shared care were in place and in the main worked well for patients most of the time. The leaders investigated when potential gaps were highlighted.

All administration staff were responsible for completing the list of tasks set up each day and the processes were well-rehearsed and understood by staff.

People had no specific feedback on this area.

Staff and leaders described the positive impact of having access to a well-resourced and knowledgeable social prescribing service.

The GP partners discussed local initiatives and what was available to patients to support them to live healthier lives. The practice had NHS health Checks undertaken by nurses and assisted roles provided by the Primary Care Network (PCN) to help.

The practice was involved in all national screening services projects and take-up was significantly lower than other practices in the area. Leaders discussed recent changes that had taken place to try and increase the uptake of cervical screening and childhood immunisation. This included allocating a dedicated staff member with language skills and lived experiences related to a specific community, to speak to women and carers about their fears and anxieties.

Systems were in place to identify patients who needed extra support and direction to relevant services. This included patients in the last 12 months of their lives, patients with a long-term condition, those at risk of developing a long-term condition and also carers.

Systems were in place so that patients were told when they needed to seek further help and what to do if their condition deteriorated.

Evidence provided by the social prescribing team indicated that the practice was good at signposting people for social support when needed and this had a positive outcomes for patients.

The practice, however, had only identified 1% of the patient list as carers. This is below the expected average for practices of 3% or more.

Feedback from people using services was mixed.

Results from the 2024 NHS GP patient survey showed that people felt their health needs were monitored appropriately and also explained to them. For example 86% of people who responded to the survey felt the healthcare professional they saw had all the information they needed about them during their last general practice appointment and 90% felt their needs were met during their last general practice appointment. These figures were in line with local and national averages.

People also said through direct feedback to CQC that health needs were monitored appropriately, they also said however, that relevant information was not always explained to them.

Leaders discussed a list of quality improvement audits and improvement projects conducted at the practice.

Leaders described that on the strength of a completed diabetic screening audit, plans were in place to commence a diabetic care clinic at the practice.

Evidence confirmed the practice relied on the NHS Quality and Outcomes Framework data (QoF) to identify areas that were working well or needed to improve.

Trainee GP’s also completed research and audits into areas of clinical interest, for example Opioid prescribing; Gout and Allopurinol and cancer diagnosis review.

The practice did not have a specific audit plan, so a documented 2-year cycle audit plan was not in place. The lack of a proactive plan was limiting as this meant the practice did not fully benefit from the outcome of all projects, especially those undertaken by trainee doctors because the rotation meant a 2-year cycle for audits was difficult unless overseen by another clinician.

As part of the assessment a number of clinical records were reviewed by a CQC GP specialist advisor. The results from the searches demonstrated there were processes in place to monitor people’s care and treatment, particularly if they had long-term conditions. The provider took immediate action when it was noted that the processes needed to be strengthened.

However, we noted that the practice was not aware of information about performance related to patient feedback, for example the patient list has reduced significantly during the past three years. When this was raised the partners had not conducted any review to identify the cause.

Processes in place needed to be monitored and audited for effectiveness.

The results from the clinical searches undertaken identified areas for improvement for confirming that patients prescribed high-risk medicines were always correctly monitored and that people with diagnosed and undiagnosed diabetes had been provided with required information, care and treatment. Follow-up information from the practice and during the inspection visit confirmed that these findings had been due to incomplete records.

Clinical searches relating in all other areas were positive and demonstrated there were effective approaches to monitor and improve people’s health outcomes through referral, discussion and advice based on best practice.

Patients records had been completed in all instances, however it was noted that some of those looked at lacked detail.

People commented that when they received information from GP’s about care and treatment it was in a way they could understand. People also said GP’s listened.

Staff confirmed they had completed mental capacity and consent training.

There were systems and practices to ensure people understood the care and treatment offered or recommended. This helped them make an informed decision. Staff had completed consent and mental capacity training which was up to date.