Wellspring 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 rated this key question good. This meant people’s needs were met through good organisation and delivery.

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.

The service recognised the diverse population needs and fully understood their service’s demographic and language barriers. For example, invitations for cervical smear clinics and childhood immunisations were available in different languages to try and encourage attendance. Translators were utilised to assist in booking of appointments, face-to-face consultations or telephone consultations where required.

Our review of clinical records showed people were supported to understand their condition and were involved in planning for their care needs. They were also involved in decisions about their care. People told us that they were listened too, however, they would like additional time for the GP to explain treatments in more depth. The nurse at the service told us, “it’s their appointment,” “I allow the person to tell me what they want to tell me.” The nurse also told us that if they had any concerns about the person, they would schedule an electronic reminder to ring the person to see how they were. We were assured that safety netting advice to come back if their condition worsens was provided.

Accessible standards and barriers to care were considered for people, with alerts added to medical records so that reception were aware upon contact that the person had additional needs. For example, people who were blind or hard of hearing were collected from the waiting room by the clinicians, a hearing loop was installed at reception. People with autism or a learning disability were offered a quiet place to wait for appointments.

The service reached out to people with learning disabilities and their carers and encouraged them to accept an invite for a learning disability health check.

The service understands the diverse health and social care needs of the people that use their service and tailors its support to meet those needs. This includes understanding the needs of people stemming from protected characteristics under the Equality Act and those at most risk of a poorer experience of care. For example, the service reached out to religious groups and women’s groups to promote the importance of cervical cytology and childhood immunisations and the provision of outreach clinics to promote the importance of men being checked for prostate cancer.

The service held a register of carers and appointed a dedicated carers’ champion who supported this group of people. Carers were signposted to support groups, and all staff were aware of the carer’s champion role. Processes were in place to record when new people registered with caring responsibilities and the practice routinely checked on carer’s wellbeing.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service had access to interpreter and translation services, including British Sign Language. Information about the need to book for an interpreter was recorded on people’s records and additional time was provided for appointments. Staff told us they had access to services for translating documents into appropriate languages, including into English. A hearing loop was also available. People were informed as to how to access their care records.

A range of information on aspect of health for all ages and local support groups were available in the practice and via the practice website. Health information leaflets were available were available in a range of difference languages. The service broadcasted health promotion information using social media, for example, via their own WhatsApp channel and YouTube videos on how to use the NHS App.

We saw notice boards within the waiting room which communicated information for people. For example, carers and young carers, men’s health, women’s health, cervical cytology promotion, in-house research projects, friends and family survey feedback board and a board promoting general health and wellbeing. The PPG also had their own notice board.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

We spoke with a member of the Patient Participation Group (PPG) who told us that the PPG membership had very few members since the covid pandemic. The member told us the service “always shared what was happening” and “kept us informed.” For example, the merger with Modality, implementation of the triage system, financing of services. “It is a positive relationship”. We were told that “the merger had resulted in easier access to appointments and easier and quicker access to clinical information on the NHS App”. The PPG member also told us that the PPG had helped to conduct patient surveys; hosted a coffee morning and invited Cancer Research to engage with people.

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. For example, results from the FFT for the period July 2025 showed that an average of 91% of people felt that the practice was very good or good and would recommend the practice to their friends and family.

We saw complaints were managed in line with the service’s policy. Complaints reviewed showed the practice responded to feedback appropriately, openly and in a non-defensive manner. Learning from complaints was evident and staff were able to identify changes made as a result of patient feedback. For example, a complaint pertaining to a delay in diagnosis of asthma and the prescribing of appropriate medicine. Lessons learnt from the complaint included reinforcing the importance to record comprehensive medical records, and the implementation of additional support from the experienced asthma nurse for the clinical team.

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

Leaders told us that the aims of the total triage system they used to manage appointment requests were to make sure people accessed the right clinician or service through their first contact with the practice. The appointment system had been altered to balance the demand for on-the-day and pre-bookable appointments. GPs were responsible for triaging the information. People were offered an appointment appropriate for their assessed need or directed to an alternative service. Staff were able to signpost people to the most appropriate pathways when required. For example, the pharmacy first scheme, social prescribers and health and wellbeing coaches. People were also signposted to the local urgent care centre when appropriate.

People who required routine appointments outside of the usual working hours had access to evening and weekend appointments. These appointments were booked on behalf of people by the service. Housebound people were offered home visits.

The practice was able to offer extended appointment durations for people with a learning disability. The service worked with the local communities to target people’s wellbeing, for example, religious groups and women’s groups to promote the importance of cervical cytology and childhood immunisations and the provision of outreach clinics to promote the importance of men being checked for prostate cancer. The service told us that these initiatives were supported by the local communities and PCN.

Staff supported people who used translation applications on their phone to enable them to communicate effectively and access the service. Texting services were also offered with translated text to enable equitable access for all people.

The service provided direct booking links to people who used services. For example, electronic booking links were sent to people who had been asked to book appointments with the pharmacist for medication review, vaccine clinics, for smear tests, and for blood tests. By using the booking link, people were able to make an appointment for the required slot directly and without using the total triage system.

National GP Patient Survey data and feedback received from people were positive about the experience of contacting the practice. Indicators showed 74% of respondents were positive about their overall experience of contacting the practice which was above the national average of 69.6%. In addition, 62.2% of respondents were positive about how easy it was to contact their GP practice on the phone, this was above the national average of 52.9%.

Feedback from people using the service was mostly positive. People felt involved in assessments of their needs and felt confident that staff understood their individual needs. People we spoke to in the waiting room, told us, “it was easy,” “it was straightforward” to obtain an appointment at the service.

Staff and leaders actively listened to information about people who were most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Feedback provided by people using the service, both to the provider and to the CQC was positive. 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. For example, extended hours appointments for workers, appointments at quiet times for vulnerable people and extended appointment times for complex cases.

The service had processes to ensure people could register at the service, including those in vulnerable circumstances such as homeless people and people from travelling communities.

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 were proactive in identifying people approaching end of life and sensitive to their needs for advanced care planning.

Records we reviewed 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.

We were assured that safeguards 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.