Castlefields Surgery

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• 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 was the first assessment 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 we reviewed 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 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 who were anxious when sitting in a crowded area, such as the waiting room, were provided with a private room to wait in or, given appointments at quieter times of the day.

Through our Give Feedback on Care service, many people highlighted excellent clinical care, including prompt referrals, effective diagnosis and treatment, proactive follow-up, support for chronic conditions, and responsive care during urgent health concerns. However, some people reported a lack of continuity of care, stating they were unable to see the same GP consistently and felt restricted by the 1 problem per appointment approach.
 

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.

The practice worked in partnership with other services to meet the needs of its patient population. For example, the Primary Care Network and the local palliative care team. The practice had tailored its services to meet the diverse needs of its community. For example, providing immunisations for people who were housebound and health checks for seasonal farm workers and members of the Travelling community. The practice was an accredited Royal College of General Practitioners and NHS Veteran Friendly practice. Staff were specially trained to understand military medical histories, providing targeted care, priority treatment, and referrals for ex-forces personnel and their families.
 

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. For example, easy read material for people with a learning disability and software that ensured people were contacted by their preferred method and language. The practice had access to interpreter services, including British Sign Language and were able to access health promotion leaflets in different languages. Alerts were added to the records of people who had specific communication requirements. Information provided by the service met the Accessible Information Standard. Patients were informed as 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 and told them what had changed as a result. Data from the 2026 National GP Patient Survey showed that 92% of respondents stated that during their last appointment, the healthcare professional was very good or fairly good at listening to them. This was comparable with the national average of 87%.

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. Complaints were a standard agenda item at clinical meetings and themes and trends were identified.
 

The service mostly made sure that people could access the care, support and treatment they needed when they needed it. Appointments could be booked through an online request form, telephone or in person. We saw that urgent on-the day and pre-bookable appointments were readily available with both GPs and nurses. Extended opening hours for pre-bookable or same day routine appointments were offered at local GP practices.

Data from the 2026 National GP Patient Survey showed that 66% of respondents were positive about the overall experience of contacting their GP practice. This was comparable with the national average of 73%. It also showed that 62% of respondents were positive to how easy it was to contact their GP practice on the phone. This was comparable with the national average of 57%. In response to the National GP Patient Survey data and from feedback from members of the community, the provider had identified changes to improve access to the service. For example, they had extended appointments for people with a learning disability. People could access the service to suit their needs for example online, in person and by telephone. Staff followed processes to ensure people could register at the service, including those in vulnerable circumstances such as homeless people and Travellers. Staff used systems to capture and review feedback from people who used the service, which included those who did not speak English or have access to the internet.

The practice operated a total triage system requiring a patient to complete an electronic form online to request an appointment. If someone was unable to complete the online form, receptionists offered to complete it for them. There was a duty clinician based within the reception area so receptions could ask for advice if someone rang or walked into the practice. Patient feedback, received through our Give Feedback on Care service, was mixed regarding the triage system. Many patients praised the practice's online triage and booking systems, reporting quick responses, same-day appointments, effective referrals, and good management of long-term conditions. However, the most common concern raised with us was difficulty accessing GP appointments, including long waits, perceived over reliance on online triage, the inability to obtain face-to-face appointments, and being directed to pharmacies, NHS 111, or other services.

The practice had carried out an audit of people who failed to attend for their appointment. Learning was identified from the results and changes made. For example; to stop using email or the NHS App as the sole method of telling a patient about a booking; and to send reminders 1 to 2 hours prior to appointments to remind patients who may forget. The practice had also participated in the Improving Access to Primary Care project to support the improvement of access to and satisfaction with Primary Care.

Treatment rooms were available on the ground floor, there was level access to the practice and an automatic door had been fitted to the entrance. To ensure that the diverse needs of patients were considered, the appointment calling system included audio and visual announcements.
 

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.

Staff treated people equally and without discrimination. Leaders proactively sought ways to address any barriers to improving people’s experience. For example, a monthly dementia drop-in clinic was provided within the practice for people with dementia, or their carers, to provide guidance and support. The practice worked with the Primary Care Network to deliver well-being events for people. For example, support for people experiencing poor mental health. The practice had a digital support champion who provided drop-in clinics for people who were unable to use the NHS App.

Staff understood the importance of providing an inclusive approach to care and adjusted support equity in people’s experience and outcomes. Staff followed processes to ensure people could register at the service, including those in vulnerable circumstances such as homeless people and Travellers. Staff used systems to capture and review feedback from people who used the service. For example, the Friends and Family Test and a comments box.
 

People were supported to plan for important life changes, so they had enough time to make informed decisions about their future, including at the end of their life. The practice worked closely with the palliative care team to support this and maintain, and regularly review, the care provided to this group of people. The practice carried out audits to monitor that people were supported to die in their preferred place of death. They told us the audit demonstrated improvements needed to be made in this area and a dedicated member of staff was reviewing their processes.

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.