Balaam Street Surgery

On this page

• 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.

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.

The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs. Feedback from patients reflected this with 99 percent of respondents to the 2025 GP Patient Survey stating they felt involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment.

Care plans reflected physical, mental, emotional, and social needs of patients. Our review of clinical records showed patients were supported to understand their condition and were involved in planning for their care needs.

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

We saw the practice worked in partnership with other services, such as pharmacies, district nurses, social services and palliative care teams to meet the needs of its patient population. The practice tailored its services to meet the diverse needs of its community and implemented measures to encourage attendance at national screening programmes. Leaders at the practice developed in-house clinical decision-making documents to ensure consultations and diagnoses represented consistency and continuity.

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

Information to promote the uptake of cancer screening and immunisation programmes was available in a range of languages. The practice had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard. Patients were informed as to how to access their care records.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

We saw complaints were managed in line with the practice’s policy. Learning from complaints was evident and staff were able to identify changes made because of patient feedback, including complaints.

The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

The National GP Patient Survey showed that 53 percent of patients found it easy to get through to the GP practice by phone, compared with the local average of 51 percent. This reflected conversations held with patients during the site visit, as there was a mixed response regarding patient access to appointments.

The practice was aware of the low patient satisfaction in relation to access to appointments and the provider implemented several changes to improve access. The practice invested in an online platform in which GPs were able to respond to patient queries without the need to speak on the phone. This platform was promoted on the practice website, with leaders providing a video tutorial on how to access and use the application. The practice employed further reception and administrative staff to answer more calls and invested in technology and screens to increase productivity to respond to patients more quickly.

The practice analysed in-house patient feedback they received from the online platform they used (AskMyGP). The results from the survey showed 65.5% of patients provided positive feedback with positive comments focused on appointment access and treatment received from staff. The practice developed an action plan based on the feedback received to improve services.

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.

Feedback provided by people using the service, both to the provider as well as to CQC, was 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 experience and outcomes. For instance, the practice had a loop device to help patients with hearing aids. The premises were step-free, and the practice employed a staff member who was able to use British Sign Language. The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and Travellers. Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to the internet.

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 review 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.