Partners in Health

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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 looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination.

This is the first inspection for this service since its registration with CQC.

This key question has been rated as Good.

People were involved in decisions about their care. The service worked to reduce health and care inequalities through training and feedback. People received fair and equal care and treatment. Requests for appointments were allocated based on clinical needs. The service understood their patient population. Changes were identified to improve the service where required.

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.

The service placed people at the centre of their care and treatment, ensuring decisions were made collaboratively in response to changes in individual needs.

Our review of clinical records confirmed that patients were supported to understand their conditions and were actively involved in planning and decision-making regarding their care. Regular multi-disciplinary meetings were held with relevant professionals and services to discuss and plan person centred care and treatment so that people’s needs could be met holistically. Through regular appointments, staff developed meaningful relationships with patients and adjustments were made to support those with additional needs, including offering longer appointments for patients with a learning disability or other protected characteristics under the Equality Act 2010. We evidenced reception staff consistently treated people with dignity and respect, offering choice, recognising and responding to their individual needs.

The service had an exceptional understanding of the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The service worked proactively in partnership with other services to meet the needs of its patient population, working with the local PCN and Integrated Neighbourhood Team (INT) in the creation of multidisciplinary services to ensure that patients at highest risk received proactive, coordinated and equitable support. For example, a weight management single point of access programme pilot, which offered telephone clinics, to improve accessibility and efficiency. A Red Risk Diabetes Service and a Red Risk Respiratory Service that employed a RAG risk stratification approach to identify patients most at risk and who may require more intensive therapy and multidisciplinary approach to their care. The aim of this service was to increase levels of engagement with preventative care and long-term condition management. Feedback, obtained by the service, from people using these services reported that the facilitator delivered a friendly and informative session with insightful information presented in a relevant and easy to follow format. We saw evidence that showed an increase in people attending the clinics, reduced waiting times, reduced hospital admissions and reduced referrals to secondary care. Acupuncture was available to manage anxiety. A smoking cessation service was also provided helping to reduce healthcare inequalities in minority groups of people.

The clinical staff team provided continuity and stability with some requirements for locum staff, who were regularly or temporarily employed by the service. We evidenced the appointment system and saw how staff encouraged continuity of care by enabling people to request and see the same healthcare professional. Staff worked collaboratively to meet the needs of patients across all areas of the service. Our review of the clinical system demonstrated that referrals to other services were made by a dedicated person to ensure they were done in in a timely manner, and information shared by other services was managed effectively to support good outcomes for people. Staff highlighted the benefit of QR codes to assist in the recording of patient data. This enabled information to be current and reduced the potential for data input errors.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service met the Accessible Information Standards. Staff told us how they encouraged patients and their carers to inform staff of their communication needs and highlighted the information on the patients’ electronic record. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. This information was easy for people to find. This included a clear, accessible service website and digital leaflets for patients and were available in different languages, offered by an ICB approved language service.

People were supported to be actively involved in decisions about their care and treatment. Staff demonstrated their understanding of the importance of listening to people. The service made it easy for people to share their experiences or raise concerns. Information on how to provide feedback or make a complaint was clearly displayed on the service website. People could raise concerns in person, in writing, or by email, and those who did were listened to and received a timely response. We reviewed a sample of complaints received by the service and found they were handled in line with the provider’s policy and responded to appropriately. The service had a dedicated member of staff who dealt with complaints. Learning from complaints, compliments and other feedback was evident and staff were able to identify changes made because of people’s feedback. This included telephony functions to reduce long waits at peak times, additional staff to improve response times, new digital data loggers to record refrigeration functions and additional signage for emergency kit bags.

The service made sure that people could access the care, support and treatment they needed when they needed it.

The service anticipated that some people would find difficulties accessing an on-line booking system. Evidence collected from people’s feedback, demographic data and telephony data, indicated that a system where appointments were made in person or over the phone ensured that people were not digitally excluded. Administrative requests (such as fit to work notes) could be made via a digital form for those who wished to use this service.

The National GP Patient Survey (GPPS) 2024, identified that 65% of patients responded positively to the overall experience of contacting the GP practice, and the percentage of people who responded positively to the overall experience of contacting their GP practice was 49%. This data was slightly below the national averages or 69% and 52%. Both premises had appropriate accessibility arrangements internally and externally.

New processes to reduce barriers to access were introduced, such as an improved patient task form on the website and a data-tracking phone system. Analysis of call data identified peak and quiet demand periods. Staffing levels were adjusted accordingly to meet patient needs and optimise resources. Unverified data shows that the new data tracking system had increased the use of patient call back requests from 77 in February 2025 to 200 in August 2025, reducing call queue times, positively impacting staff and improving people’s experience.

Staff and leaders actively listened to information about people who were most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The service demonstrated a clear commitment to promoting equity of experience and outcomes for people using the service. Staff treated individuals with respect and without discrimination, and all had completed training in equality and diversity. The service had a policy to support inclusive care.

Leaders sought ways to address any barriers to improving people’s experience. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. The service supported registration for people in vulnerable circumstances, including those experiencing homelessness or recently released from secure facilities. Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have limited access to the internet. The feedback we evidenced, provided to the service by people using the service, was mainly positive.

As a result of feedback and analysis of demographic data the service understood that access to digital services was challenging for some. In response, they held an NHS Digital Support afternoon to assist patients who required extra help accessing and using online NHS App. They created a supportive space where people received one-to-one guidance on using digital tools such as the NHS App, requesting prescriptions, and accessing medical records. Staff worked closely with people to build confidence and ensure that everyone, regardless of digital ability, could benefit from the convenience and accessibility of online healthcare. This initiative reflected the organisation’s ongoing commitment to reducing digital exclusion and promoting inclusive, accessible, and patient-centred care.

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. Staff attended multi-disciplinary meetings to discuss patients receiving end-of-life or complex care. Clinical records were updated to reflect any actions or changes made to their care plans. Our review of clinical records showed people were supported to consider their wishes for their end-of-life care. Care plans documented a do not attempt cardiopulmonary resuscitation (DNACPR) decision when it had been made. Families and/or carers had been involved in these decisions when the person lacked the capacity to make them independently. This information was shared with other services, such as the out-of-hours services, when necessary.