Colney Hatch Lane Surgery

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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.

We assessed all quality statements for the key question of responsive.

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.

Feedback from people using the service was generally positive. The feedback obtained was based on the most recent GP Patient Survey results (published at the time of this assessment), and the prior six months Friends and Family Test (FFT) results provided to us by the service. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs.

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.

The service operated a system where patients were generally able to consult with the GP they were registered with, which allowed for personalised care as well as continuity of care. Patients also had the choice to choose a different GP if they wished to.

Our review of clinical records showed patients were supported to understand their condition and were involved in planning for their care needs. They were also involved in decisions about their care.

The service recognised the diverse population needs and fully understood their service’s demographic and possible language barriers. Translators (in-person or via the use of online translation software) were utilised to assist in booking of appointments, face-to-face consultations or telephone consultations where required.

Accessible standards and barriers to care were considered for people, with alerts added to medical records so that reception staff were aware upon contact that the person/patient had additional 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.

The service worked in partnership with other services to meet the needs of its patient population. The service had tailored its services to meet the diverse needs of its community. There were established mechanisms for engaging with other community healthcare providers.

The service told us that whilst they do not have regular face-to-face meetings with community healthcare services, regular communications with these services were maintained through emails and telephone calls, to ensure that continuity of care was provider to patients.

We did not look at this quality statement of providing information. The score for this quality statement is based on the previous rating for this key question from the previous provider for this location. The previous provider of services at this location is a partner at this service.

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

The service routinely asked people to complete Friends and Family Test (FFT) feedback forms and reviewed the feedback for any trends or themes. Our analysis of data sent to us from the service revealed most patients who completed the FFT forms felt that the service was very good or good and would recommend the service to their friends and family.

The service had systems 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. However, the service did not have any pathways in place for patients to share their experiences of the service with each other.

The service did not have an active Patient Participation Group (PPG). The service told us that this was a priority for them to establish, however there was no evidence that any opportunities were taken, or attempts made to establish a PPG in the 12 months prior to our assessment.

We saw complaints were managed in line with the service’s policy. Complaints reviewed showed the service responded to feedback appropriately, openly and in a non-defensive manner. There was no evidence that learning from complaints was discussed at staff meetings or changes made because of patient feedback, embedded within the service.

National GP Patient Survey data and feedback received from people was mixed regarding their experience of contacting the service. Indicators showed (at the time of this assessment) 59% of respondents were positive about their overall experience of contacting the service which was below the national average of 67%. In addition, 49% of respondents were positive about how easy it was to contact their GP practice on the phone, this was below the national average of 50%.

The service made sure that people could access the care, support and treatment they needed when they needed it. The service had extended appointments as standard for people with a learning and/or physical disability. Treatment rooms were available on the ground floor, and a ramp and power assisted door had been fitted to the entrance.

People could access the service to suit their needs for example online, in person and by telephone.

The appointment system was flexible to adjust to the demand for appointments on the day and pre-bookable appointments. The service used triaging for appointments and requests, allowing patients to submit requests online and by telephone. GPs were responsible for triaging the information. People were offered an appointment appropriate for their assessed needs.

Staff were aware of the needs of the local community and made adaptations in line with this. For example, there was a ramp to the main door at the entrance, a hearing loop and a parking space for disabled persons.

Late night and weekend appointments could be booked by the service for patients who were at work during normal working hours. These appointments were provided through the local Primary Care Network (PCN).

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.

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. The service had processes to ensure people could register at the service, 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. The service identified patients approaching end of life and were sensitive to their needs for advanced care planning.

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. For example, the out of hours services and other health care professionals involved in the care of this group of people.

Processes were in place to ensure that decisions were made which were in the persons’ best interest. When people did not have mental capacity to make their own decisions regarding end-of-life care and priorities for care and treatment. family members and carers were involved in decision making.