During an assessment under our new approach
Date of Assessment: 5-10 August 2026.
Castlefields Surgery is a GP practice and delivers services to approximately 11,593 people under a contract held with NHS England. The practice is 1 of 8 GP practices within the Archvale Partnership. According to the latest available data, the ethnic make-up of the service area is approximately 92.2% White, 3.5% Asian, 2.2% Mixed, 1.4% Black and 0.7% Other. Information published by the Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 7th decile (7 of 10). The lower the decile, the more deprived the practice population is relative to others.
This was a full comprehensive assessment. We undertook this assessment because the practice had not been assessed since the new provider took over in October 2024. We assessed all the quality statements from across all 5 key questions. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff mostly managed medicines well and involved people in planning any changes. In response to our findings, the service acted quickly to address issues relating to patient non-compliance with monitoring for high-risk medicines.
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on the latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people to make decisions in people’s best interests where they did not have capacity.
People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service effectively supported staff well-being.
People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and most people were confident the service took it seriously and acted on it. We received mixed feedback from people regarding access to appointments. Many people were positive about the total triage system however, others found it difficult to navigate. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
Leaders and staff had a shared vision and culture based on listening, learning and trust. Staff were very positive about the culture within the practice stating it was open and supportive. Leaders were very visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.