Ottershaw 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 75 (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 patients including those related to protected characteristics under the Equality Act.

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. Results from the 2025 NHS England GP Patient Survey confirmed that 100% of respondents felt they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment.

An active patient participation group met with leaders to discuss issues affecting the patient population, to enhance their understanding of the patient experience and identify areas where improvements could be made.

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.

We saw the practice worked in partnership with other services to meet the needs of its patient population. For example, the practice had established links with the local Frailty Hub and patients benefitted from support from these services.

Referrals were managed efficiently and all staff understood their responsibilities within the process. Fail-safe mechanisms were introduced recently to reduce risk from human error and to support positive patient outcomes.

Ottershaw Surgery delivered services as part of the local Primary Care Network (PCN) and several staff worked across all 3 practices who formed the PCN, which promoted consistent care locally. When necessary, because of staff sickness or leave, locums GPs were used by the practice. Regular locums who were known to the practice minimised risk from unknown staff and assured leadership of their competence and safe practice.

The practice supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. The practice had access to remote interpreter services, including British Sign Language. Patients were informed as to how to access their care records.

Digital flags were added to clinical records for people with differing communication or access needs to address barriers to care. This alerted staff to specific needs to enable them to adapt their care provision. For example, information leaflets sent to patients before a learning disability health check, could be provided in easy-read format to enhance their understanding and reduce anxiety about the process.

The practice 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 as a result of patient feedback, including complaints. The practice website contained information about how to give feedback or make a complaint and this information was also displayed at the practice.

Leaders provided us with information about quality-improvement work that had been undertaken in response to complaints. Staff told us how learning was shared without blame to provide opportunities for learning and development, and to improve standards of care.

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

The practice had conducted a patient survey in September 2025 about how care was accessed, to understand preferences for contacting the practice. 772 people responded and 96.5% expressed they did not wish to change the current system. This meant that people continued to be able to access the service to suit their needs, online, in person and by telephone.

People told us in their feedback they were happy with how they could contact the practice. This was reflected in the 2025 NHS England GP Patient Survey results with 93% of respondents describing their experiences of contacting their GP as good. This was considerably higher than local and national results of 73% and 70% respectively.

The practice delivered all services at ground level and there was a ramp at the entrance, to allow access for all.

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.

Positive feedback was provided by people using the service, both to the provider and to CQC. 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.

The practice had identified vulnerable patients who may be in need of extra support, and digital flags were added to records for staff awareness. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes.

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.