Birchwood 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. We looked for evidence that the service involved people and treated them with compassion, kindness, dignity and respect. This is the first inspection under our new methodology for this service. 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. For example, care plans would include communication needs, accessibility requirements and if any additional support was needed when making an appointment. They were also involved in decisions about their care. The 2024 national GP patient survey showed the practice was in line with local and national averages for involving people in their care and decision making. The practice patient participation group were mostly positive about the practice and told us they wanted to become more involved with supporting the provider to ease their workload.

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. The practice had tailored its services to meet the diverse needs of its community, for example, building relationships with community groups to promote the take up of screening programmes.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. As the practice did not formally collate patient information, there was no documented evidence of actions taken, although patient feedback told us that changes were made. The practice acknowledged that a formal approach to recording patient feedback was required. Information to promote the take up of screening and immunisation programmes was available in a range of languages, such as Polish. The practice had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard which showed how patients were informed 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 or told them what had changed as a result. We saw complaints were managed in line with the practice’s policy. For example, we sampled complaint responses and saw they included information about escalation to the Parliamentary Health Service Ombudsman. Learning from complaints was seen. Staff were able to identify changes made as a result of patient feedback, for example, the introduction of telephone call waiting. Patients were able to make complaints, in person, via the website, and in email form. Patient feedback told us that they were assured of a complaint being handled promptly.

The service was open Monday to Friday 8am to 6.30pm. There was an extended access service open from 6pm to 8pm weekdays and 9am to 5pm Saturdays. All other appointments outside of these hours were made through NHS 111. This ensured that people could access the care, support and treatment they needed when they needed it. In response to the 2024 National GP Patient Survey data and from feedback from members of the community the provider had identified changes to improve access to the service. People’s feedback told us that access to the service to make appointments was above local and national averages at 74%. The provider had implemented new telephone systems to include a call back function. For patients who found it difficult to complete online access, the reception staff would complete the forms with the person if they telephoned or visited the practice. Treatment rooms were available on the ground floor and there was level access to the entrance.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was tailored in response to this. Feedback provided by people using the service, both to the provider as well as to CQC, was mostly positive. The 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. There was access to social prescribers at the practice. There was no measurable data available to monitor patient outcomes for addressing barriers to improving health. Staff understood the importance of providing an inclusive approach to care and adjusted support equity in people’s experiences and outcomes. The provider had adequate governance processes to monitor and improve access; for example, there was a formal approach to monitoring access effectively. The staff would monitor the telephone calls coming in and adjust staffing as required, however, in busy periods, the management team would support staff. The provider did ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and Travellers. Staff used registers 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, such as palliative care and community teams.