Hope House 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

Responsive - We looked for evidence that the service met people’s needs through good organisation and delivery.

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 provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood their options.

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 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. Care plans reflected physical, mental, emotional, and social needs of people including those related to protected characteristics under the Equality Act. Our review of clinical records showed people were supported to understand their condition and were involved in planning for their care needs and in decisions about their care.

The service had worked alongside and communicate with the local primary care network (PCN) to deliver care and review performance as part of the extended access arrangements. This included the housebound and care home service to improve the timeliness of care provided. We received feedback from local partners including local care homes, which identified positive themes of how they were supported and offered person-centred care to their residents. The service ensured nurses visited people who were housebound to complete chronic disease checks, with over 200 visits being completed in the last 12 months. The service also identified above average number of people with learning disabilities registered against national averages, and as a result improved the uptake of learning disability checks through more active engagement with people and where appropriate their carers. In 2024, 92% of patients who did not actively decline a check received one.

The service regularly reviewed the National GP patient Survey results and used these to target areas for improvement. In 2025, 94% of people described their overall experience of Hope House Surgery as good, compared with the national average of 75%. This had improved from 88% in 2023 and 91% in 2024. The percentage of respondents to the National GP patient survey who responded positively to the overall experience of contacting Hope House Surgery was 89% with the national average being 70%.

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. The service had tailored its provision to meet the diverse needs of its community, for example, building relationships with community groups to promote the uptake of screening programmes. For example, people were signposted to local initiatives such as sexual health clinics, sleep-based therapies and mental health self-referrals.

The service had access to a social prescriber who offered people a range of local health and wellbeing initiatives. The social prescriber told us the service was part of a project to ensure people who were registered as carers were invited to dedicated clinics which included health screening. This helped to identify any undiagnosed conditions as well as providing mental health support. The service identified cervical screening uptake had reduced and was below national targets. As a result, the service undertook a survey to highlight barriers for attendance. The main reason was in relation to people needing to take time off work. Following the survey, the service offered both pre-bookable and drop- in sessions from January to March 2025. This helped facilitate attendance for those who have not previously attended and increased uptake to above the national target.

There were established mechanisms for engaging with community healthcare providers. Multidisciplinary meetings were held regularly for people with complex needs such as with community district nursing and community mental health services. The service ensured longer appointments were available for those with additional needs. The service took proactive steps to identify and remove barriers so that people could access care and support when they found it difficult to use services. For example, the service ensured people who were recognised as a military veteran were invited to annual reviews, as part of their recognised accreditation. The service provided staff with additional training to understand military service-related health needs, including referrals, and prioritising access for related conditions, such as mental-health support.

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

Information to promote the take up of screening and immunisation programmes was available in a range of languages. The service made reasonable adjustments to meet individual needs in line with the Accessible Information Standard. People were informed as to how to access their care records. There were arrangements to ensure confidentiality at the reception desk and a separate telephone hub operated by an administrative team to prevent sensitive information being inappropriately shared or overheard.

The service identified through feedback that some people experienced difficulty in understanding how to use the NHS App. In May 2024, the service undertook a project to increase utilisation of the NHS app. This increased logins by 67%. The service recognised many people struggled to access information related to their healthcare as this is increasingly available digitally. To address this health inequality, the service worked with Age UK to set up and host a digital café to support people with digital access and understanding their care records.

The service carried out a quality improvement audit following the implementation of the digital ‘triage first’ system in September 2023. This meant more people were directed to the service website in order to access the appointment request form. As a result, the service developed a new website which was assessed by BaNES Enhanced Medical Services (BEMS), a supporting local GP federation. The service carried out the recommendations provided by BEMS to improve accessibility of information including the structure of content and the usability and interface with mobile devices. Results from the audit following the website development in January 2024 demonstrated a 66% improvement in the criteria set out in the ‘GP website benchmark and improvement tool’. This project was recognised by the commissioners used to share best practice outcomes for improving digital inclusion across the local area.

Prior to the launch of digital triage (‘triage first’), service leaders discussed the proposal with the Patient Participation Group (PPG) and refined information and guidance for people based on feedback. Following this, the service communicated service changes with people and held drop-in practical sessions during planned flu clinics.

Staff members had visited local primary schools to share their experience on healthcare and a local secondary school to talk about careers in medicine. The service also hosted work experience placements and plan to take on local T-level students in 2026. The service offer volunteering experience at regular flu clinics.

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 The service identified themes from a review of complaints and learning was shared with staff. Staff were able to identify changes in response to feedback and complaints. For example, as a result of administrative and record-keeping errors relating to referrals, automated referral reminder alerts were added to clinical systems to prevent the likelihood of reoccurrence. The service also provided additional training in relation to data security. During our assessment, we reviewed a sample of complaints and noted these were investigated and responded to appropriately in line with service policy. Where appropriate, people were provided with an apology and signposted to the Parliamentary and Health Service Ombudsman.

The service made sure people could access the care, support and treatment they needed when they needed it. National GPPS data showed higher than average positive results for accessing the practice. Data showed 89% of respondents were positive about their overall experience of contacting the service which was comparative with the national average of 67%. With 86% of people feeling they waited the correct amount of time, compared with the national average of 67%.

Feedback from people collected by the service was also positive in relation to accessing services which suited their needs. For example, online, in person, by telephone and could also submit medical or admin requests online via the practice website. The service offered extended access arrangements outside of normal working hours provided by a GP and a nurse practitioner on Saturday mornings and weekday evenings through the local primary care network (PCN). The service had utilised PCN resources to provide a co-ordinated package of care, such as mental health practitioners, first contact physiotherapists and pharmacy technicians.

People received assessments in a setting appropriate to their needs. Those living in a care home, received a ward round on a weekly basis from a GP. Those who were housebound were offered appointments with GPs and a first contact paramedic as well as having their chronic disease checks with a nurse. The service made adaptions for people’s needs, such as visiting at day centres.

We saw evidence of audits completed in relation to access performance, such as appointment capacity and demand data, appointment waiting times and ‘Did Not Attend’ (DNA) rates per GP to assess performance. The service had also reviewed audits of telephone access data which included the total number of inbound calls daily; queue waiting times and call abandonments. This also helped provide oversight to rota management and staffing arrangements to meet access demand. The service made changes to the administrative telephone staff rotas and staff support during busy periods of the day and during different days of the week through identifying trends. The service demonstrated a reduction in average call waiting times and abandonments from July 2025 to September 2025 as a result of these changes.

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, via feedback surveys as well as to CQC through ‘give feedback on care’, was overall positive. For example, we saw feedback themes which highlighted people were well informed and involved in decisions about their care and staff treated people equally, 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. 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 online services.

We received feedback from Patient Participation Group (PPG) members who praised the senior leadership team, stating they listened and acted upon feedback from the people who used services, which developed a community-focused service that was user friendly, supportive, and modern.

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 remote review of clinical care records 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. There was a process in place to ensure the register was accurate so staff could provide more appropriate and patient-focussed care to people. People on the service’s palliative care register were reviewed in monthly multi-disciplinary meetings, including mortality reviews, which were shared amongst clinical staff for wider learning. Clinical staff had completed appropriate training on how to have effective and sensitive conversations with people and their families about their wishes and preferences for emergency care.