Cavendish Health Centre

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We assessed all 7 of the quality statements from this key question, person-centred care, care provision, integration and continuity, providing information, listening to and involving people, equity in access, equity in experiences and outcomes, and planning for the future. Our rating for this key question is good. At our last assessment, we rated this key question as outstanding as the practice offered a range of services that were not common at the time but are now standard practice, this included out of hours appointments, online services, mother and baby clinic, email, telephone and skype consultations.At this assessment, the rating has changed to good.

This service scored 75 (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 made sure people were at the centre of their care, treatment choices and they decided in partnership with people, how to respond to any relevant changes in people’s needs. The staff we spoke to demonstrated a good understanding of their patients and the practice had developed the service in response to those needs. Alerts were added to patient records so staff could identify additional needs or preferences. The practice maintained lists of patients with specific needs, including those with learning disabilities, and actively identified patients who were carers.Staff ensured that carers are correctly coded on the clinical system register and an alert is added to the clinical system for whole team awareness. The practice demonstrated patient involvement in their care and treatment, for example, in DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) decisions.

The practice had a GP assistant who contacted patients who were hard to reach; for example, people who had not responded to a long-term condition appointment invitation, or practice requests for monitoring of medicines.Patients told us that they could request to see their preferred GP.

Leaders explained they met regularly with multi-agency staff to discuss and improve outcomes for people with complex needs.The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and promoted continuity. The practice was actively involved in their local primary network, where they worked with other practices to improve the local health inequalities. Patients could book appointments online, through the hub, or by telephone, longer appointments were offered to those with more complex needs. People in vulnerable circumstances were able to register with the practice. Clinical staff held multidisciplinary meetings to ensure joined-up care.In addition, the practice supported primary care professionals to meet the needs of their LGBTQ patients.

Staff and leaders told us they were part of the Westend Marylebone Primary Care Network (PCN). They also had PCN and Additional Role Reimbursement staff-led clinics including diabetes care, a social prescriber, and clinics for primary care.We saw the practice worked in partnership with other services to meet the needs of its patient population. The practice had tailored its services to meet the diverse needs of its community, for example, building relationships with the community, information was available on a range of services people could access or self-refer to, which included carer support, drug and alcohol, and mental health services.

The service supplied appropriate, accurate, and up-to-date information in formats that were tailored to individual needs. The practice website also contained full details on how to make an appointment, the services available, and resources. Staff told us information was available to patients in the reception area and on the practice's website, and this was observed during the site visit. They would highlight patients' records if they had any communication or accessibility needs, which staff gathered when a patient registered. The practice had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard. Interpreter services were available for those people whose first language was not English, and for people with a hearing impairment, a hearing loop was available.

The practice had a complaints policy and process and made it easy for people to share feedback and raise complaints about their care and treatment. A member of the leadership team managed complaints, and the evidence we reviewed demonstrated that investigations were handled according to the practice’s policies. Complaints had been acknowledged, and investigated, people were given an apology, actions were taken in and learning was shared with the team in meetings. Patients were informed of appropriate actions they could take if they were unsatisfied with the outcome of their complaint.

Learning from complaints was evident and staff were able to identify changes made as a result of patient feedback, including complaints. The practice also recorded and reviewed compliments. Staff described how complaints were discussed in practice meetings, and areas of improvement were identified and shared. We saw from meeting minutes that complaints were a standing agenda in team meetings.A Patient Participation Group (PPG) representative described how practice leaders listened to and acted on the feedback shared.For example, improvements had been made so that urgent same day appointments could be booked in the morning and in the afternoon and the practice has implemented this.

The service made sure that people could access the care, support, and treatment they needed when they needed it. The national GP patient survey (2024) found 85% of patients found the reception and administrative team helpful (national 83%, local 82%).

In response to the National GP Patient Survey data, and from feedback from members of the community the practice had identified changes to improve access to the service. The leaders conducted a patient focus group to particularly address access issues. For example, they had extended appointments for complex patients. People could access the service to suit their needs for example online, in person, and by telephone. The practice was open from 8.00 am to 6.30 pm Monday to Friday, and patients had access to out-of-hours services in the evening and at weekends. The website also provided information on accessibility for the out of hours sites. Face to face, online, telephone appointments, and home visits were available either as urgent or routine. The site was accessible to people with additional needs including disabled/pram access, there was a lift and an automatic door at the entrance. Staff told us that in response to the National GP patient survey, they introduced GP follow up appointments to promote continuity, had urgent appointments and different appointments times available to allow patients to choose the best appointment times to suit their needs.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support, and treatment in response to this. The national GP patient survey found 69% of patients had a fairly to very good experience of contacting the practice (national 67%, local 70%), 85% found the reception staff very helpful (national 83% and local 81%). In addition to this 50% of patients found contact through the website fairly to very easy and 69% of patients found it fairly to very easy to contact the practice by phone (national 50%, local 58%).

Feedback provided by people using the service, both to the practice as well as to CQC, was mainly positive. Staff treated people equally and without discrimination. Leaders proactively sought ways to address any barriers to improving people’s experience and worked with local organisations, including within the voluntary sector, to address any local health inequalities. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experiences and outcomes. The receptionists had a triage process to follow to ensure they made the appropriate appointments for patients.

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. Our records reviewed showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. This information was shared with other services when necessary. The practice also offered home visits where appropriate.

Staff and leaders told us that there were regular multidisciplinary team meetings and that any safety concerns were discussed in partnership. Staff and leaders also told us that the practice had a palliative care register. We did not receive any patient feedback that directly related to planning for the future.