Adelaide 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 at the current location. This key question has been rated as requires improvement.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice usually made sure patients were at the centre of their care and treatment choices and they decided, in partnership with patients, how to respond to any relevant changes in people’s needs. The practice told us people who used services were involved in planning and making shared decisions about their care and treatment, for example, patients on the end-of-life pathway.

The National GP Patient Survey results were in line with the average for questions linked to patient centredness. For example, 80% of respondents (compared to 83% nationally and 86% locally) found the reception and administrative team helpful and 82% (compared to 87% nationally and 88% locally) said the healthcare professional they saw or spoke to was good at listening to them during their last general practice appointment.

The practice 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 practice was able to provide consistency for patients. They worked closely with asylum seekers in the area, and also with a residential intermediate care service. The practice demonstrated an understanding of the needs of these patients. Results of the National GP Patient Survey indicated that 26% of patients got to see or speak to their preferred healthcare professional when they would like to, compared to 40% nationally and locally. Although staff worked with multi-disciplinary professionals to meet the needs of patients, information shared by other services was not always managed effectively and in a timely way to support good outcomes for people. This included the management of test results and the management of patients’ records.

Leaders were not aware of the Accessible Information Standard, which included supplying appropriate, accurate and up-to-date information in formats that were tailored to individual needs. The practice had access to interpreter services, including British Sign Language.

Staff told us that confidentiality was an issue in waiting areas. There were screens in the reception area between staff and patients. Speakers had been installed to enable staff and patients to clearly hear conversations, but this had a detrimental effect on patient confidentiality.

The practice did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They did always not involve people in decisions about their care or tell them what had changed as a result.

The practice provided us with their complaints procedure. The process was not followed; responses were not always from the complaints’ manager, and we saw no examples of responses including information on how a complaint could be escalated to the Parliamentary and Health Service Ombudsman (PHSO).

Complaints about clinicians were routinely sent to the clinician the complaint was about so they could respond. We saw no evidence of any investigations into complaints about clinicians. We saw that GP partners responded to complaints about themselves and saw examples of them dismissing complaints about poor behaviour and practice, saying the allegations were incorrect. Complaint responses were made on outdated letter-headed paper that included a GP practice that no longer existed.

Some staff told us they did not know how complaints were dealt with. Leaders told us they were discussed in meetings, but there was no mention of complaints in any of the meeting minutes we saw, and when asked, leaders could not supply us with any.

People could usually access services when they needed to. Physical premises and equipment were accessible, and people were given support to overcome barriers to ensure equal access. Clinicians were available to see people for all types of appointment requests including urgent appointments.

There was a lack of understanding by GP partners and senior leaders about how the appointments system worked. We received conflicting information, with some people telling us there was a triage system and some saying this was not in place. Some reception staff stated there was no triage system and said they had not received care navigation training. Others told us there used to be a form to complete to prioritise patients’ needs, but this was no longer used due to the team being too busy.

The service received scores in line with national and local averages in the National GP Patient Survey for questions linked to access. The percentage of respondents who were positive about their experience of contacting the practice was 69% (compared to 70% nationally and 73% locally) and 63% of respondents (compared to 67% nationally and 68% locally) felt they waited about the right amount of time for their last appointment. The percentage of respondents who responded positively to how easy it was to contact their GP practice on the phone was 56% (compared to 57% nationally and 53% locally). 42% of patients found it easy to contact the practice using the NHS App (compared to 49% nationally and 53% locally). The practice manager told us they did not have an action plan in place to improve access. They said their Friends and Family feedback was in line with the National GP Patient Survey results.

Staff and leaders did not always actively listen to information about people who were most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this. Staff had received training in equality and diversity.

The practice was in an area of high deprivation. They had an informal policy that patients should pay a cash deposit to borrow a blood pressure monitor, when this would be beneficial in managing their hypertension. Blood pressure monitors had been provided for the practice to lend to patients, and there was no protocol in place regarding the need to pay a deposit. Meeting minutes from 6 May 2025 showed this had been reviewed, stating, “To continue with £10 charge encourage patients to buy their own if they have a long-term health condition.” Some staff told us they would not ask for a deposit as they disagreed with it, and some said patients did not need to pay if they did not have the means to do so. This created a system where patients were not treated equally, and consideration had not been given to the difference in outcomes for patients unable to borrow a monitor.

There were processes to ensure people could register at the practice, and people in vulnerable circumstances such as homeless people and Travellers were treated equally. The results of the National GP Patient Survey showed that 83% of respondents felt their needs were met during their last general practice appointment, compared to 90% nationally and 91% locally. and this was in line with the local and national average. 70% described their overall experience of the practice as good, compared to 75% nationally and 78% locally.

People were not always 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. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were not audited. We checked a sample of DNACPR records. The practice did not record if other agencies, such as North West Ambulance Service, had been informed of the decision. The Registered Manager told us this was because it was standard procedure, so they did not note it. We saw a record noted that the Lasting Power of Attorney (LPA) had been consulted about DNACPR decisions, but no evidence was held of an LPA being in place. There were regular multi-disciplinary meetings to discuss supporting people receiving end of life care.