Hightown Village 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 assessment for this service since its registration with CQC. This key question has been rated as requires improvement.

Feedback from patients indicated that they continued to be dissatisfied with the arrangements for access. We found that there was a breach of legal regulation relating to Good Governance. The provider did not have an effective system to seek patient views about contacting the service and getting a timely appointment, act upon them and evaluate that the action taken had led to improved patient satisfaction.

This service scored 62 (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 worked to put people at the centre of their care and treatment choices, and they decided, in partnership, how to respond to any relevant changes in people’s needs. Some partners reported that access to the practice had been challenging and that the service had not always been as responsive as they would have liked in meeting individuals’ needs. National GP Patient Survey reported lower than average patient satisfaction scores for questions linked to patient centredness. For example, 55% of patients who responded felt they had enough support from local services or organisations in the last 12 months to help them manage their long-term conditions. This was below the local and national averages of 71% and 69% respectively and 69% of respondents compared to 83% nationally and 85% locally found the reception and administrative team helpful.

Feedback from the Friends and Family Test data shared by the practice between July and December 2025 showed a higher level of patient satisfaction with an average of 80.3% of patients indicating the practice was good or very good. Many examples of how staff had taken the time to make sure people’s needs were met were shared. This compared with an average of 14% of patients who responded over the same period who felt the practice was poor or very poor.

Information about patients’ care and treatment needs were available and shared between services when required. The practice was involved in the local community and advocated for the health needs of its patients. Services were tailored to meet the diverse needs of the population, with a focus on promoting health education and preventative care initiatives. The importance of flexibility was evident in the way services were delivered. Systems were in place to alert staff to any specific safety or clinical needs, ensuring that patients received appropriate and coordinated care.

The service provided appropriate, accurate and up-to-date information in formats that were tailored to individual needs. Information was readily available throughout the practice in a variety of formats. Visual displays and printed materials were visible and relevant, including leaflets and posters offering support for patients including sexual health and smoking cessation services. Patient feedback mechanisms were in place, including forms available in the practice. The practice website contained health promotion information, including details on NHS Health Checks, screening programmes and access to mental health services. This supported patients in understanding their health needs and accessing preventative services. Safety netting advice was provided when patients were at risk of deteriorating health.

People could expect information to be tailored to their individual needs, which included, making reasonable adjustments for disabled people and providing interpretation and translation services for people who did not speak English or who used British Sign Language. People who had difficulty with reading, writing or using digital services were supported with accessible information.

Information was available at the service and online so that people knew how to give feedback about their experiences of care and support, including how to raise concerns, complaints or issues. People were encouraged to give feedback to the practice if they wished to complain about their care or treatment. Complaint leaflets were available in reception and on the practice website.

We reviewed a sample of complaints and found they had been fully responded to and included an apology when appropriate. Trends and themes from complaints were reviewed for learning and to improve services.

People had access to a newsletter on the practice website containing information about opening times, signposting to local services including emergency dental care and liver health checks, compliments about the practice and patient engagement opportunities,

Feedback relating to access was negative, however the practice had taken action to address this. At the time of our assessment the practice had not sought further feedback from patients about the actions they had taken to improve access.

The GP Patient Survey reported that 34% of people who responded felt their overall experience of contacting their GP practice was good, which was below the local and national average of 70% and 10% of respondents compared to 51% nationally felt it was easy to contact the practice using the website. Patient satisfaction for finding it easy to get through to the practice by phone was lower than average at 16% compared to 53% nationally. CQC requested feedback from patients through ‘Give Feedback on Care’. Feedback received was mostly negative regarding access to the service and experience of contacting the practice. Friends and Family Test Data shared by the practice between July 2025 and December 2025 showed that feedback regarding access was mostly negative. Some staff told us they felt there should be more GPs available on site throughout the week.

The provider reviewed patient feedback. However, they had not taken effective action to assure themselves that the changes they had introduced were having a positive impact on patient experiences of contacting the practice or getting an appointment in a timely manner.

The provider had introduced improvements to support a more efficient access model including the use of digital/online services. Information was available for people to support them to understand how to access services (including on websites, telephone messages and newsletters).

The core opening times were 8am to 6.30pm Monday - Friday. Extended access appointments were available. People could make an appointment by calling the practice, attending in person or online. There were arrangements to prioritise patients to ensure urgent needs were met on the same day. Home visits were made following an assessment of need. Patients were directed to 111 if they needed care and treatment when the practice was closed. Clinical staff were available for face-to-face appointments 2 days a week and telephone appointments with a variety of clinicians were available 5 days a week. Triage was undertaken by trained Care Co-ordinators and supported by a duty GP. Housebound patients and Gold Standard Framework (GSF) patients including those patients approaching end of life were offered a GP same day telephone appointment. Those patients who required a face-to-face appointment were escalated to the Primary Care 24 specific daytime visiting service. The practice had recently introduced a home visiting service for frail elderly patients. A call back option had been introduced to reduce wait times. Patients were supported to use the digital front door to access services and were signposted appropriately to the most suitable clinician. A newsletter had been introduced, and the practice website was updated to raise awareness of the different types of services offered by the practice and encourage alternative methods of access. An information board was accessible to patients at the practice advising them of the number of missed appointments that month to raise awareness of the importance of keeping or cancelling appointments to free up capacity.

The provider regularly reviewed accessibility feedback to ensure no group was disadvantaged by the mode of access.

Premises were accessible for people who were physically disabled and treatment rooms were available on the ground floor. Parking was limited and there was 1 disabled parking space.

Leaders sought ways to address any barriers to improving people’s experience. Staff and leaders ensured they were able to recognise patients who were most likely to experience inequality in experience or outcomes and they tailored the service to meet their care, support and treatment needs in response to this. Staff had completed specific training related to learning disability and autism awareness.

Treatment rooms were available on the ground floor, and a ramp provided disabled access to the side entrance. An intercom and CCTV system were in operation at this entrance to alert reception staff if people required assistance with getting into the building. The main entrance and entrance to the waiting area were not automatic to enable easier access for people with a disability or parent/care giver with a pram and space was limited at reception. Leaders and staff were aware of the constraints of working in a non-purpose-built premises where the team were unable to offer as many services as they would like to.

The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and Travellers. Staff understood the importance of providing an inclusive approach to care and adjusted to support equity in people’s experience and outcomes. Patients had equal opportunities to access appointments provided by a range of multi-skilled clinicians. Learning from complaints and concerns was seen as an opportunity for improvement, and staff could give examples of how they incorporated learning into daily practice.

People who used the service were provided with information to make informed decisions about their current and future care and treatment and were supported to plan for these. 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, as necessary. Multi-disciplinary meetings were held on a regular basis to discuss the needs of people receiving end of life care.