Woodstock Bower 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

The service was exceptional at making 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. We found the service understood the needs of different people and groups of people and delivered care and support in a way that met their needs and promoted equality and equity. The service had an exceptional understanding of the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity. We found the practice prioritised the diverse health and care needs of their local community. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. We found the practice had an ethos of supporting people who may face barriers to accessing care and took practical steps to ensure people received support in ways that worked for them. Staff and leaders were innovative in how they listened to information about people who are most likely to experience inequality in experience or outcomes. Staff and leaders actively used this information with an aim to provide exceptionally tailored care, support and treatment in response to this. 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.

This service scored 86 (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 was exceptional at making 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. We found the service understood the needs of different people and groups of people and delivered care and support in a way that met their needs and promoted equality and equity. They had identified those who were at risk of experiencing barriers to health care or having poor health outcomes and developed initiatives and collaborated with others to try and improve this. Multiple examples were shared. Three of note were:

As part of the early identification of health inequalities the provider had implemented a targeted paediatric vitamin and mineral screening initiative for children aged 3–8 years to promote early identification of deficiency and preventative health advice.

The practice’s involvement in wider initiatives, including the Ethnic Minority Research Inclusivity Network, the Deep End Research Alliance and research collaborations with RDASH, demonstrated a broader commitment to addressing health inequalities and improving population health. We received positive feedback from patients who valued being offered the chance to take part in research and described the meaningful impact it had on their lives.

Leaders recognised that around 11% of the practice population were living in negative household budgets and understood the significant impact that financial stress had on people’s health. In response, and following a suggestion from the ICB, they worked with Rotherham Citizens Advice in April 2025 to pilot a self‑serve debt‑advice kiosk in the waiting area. The kiosk was installed in May 2025 and, after the trial period ended, the practice requested to retain it. It remained in place, with the practice covering the ongoing running costs. Leaders raised awareness through posters in the surgery and in nearby community locations, including a pharmacy and a mosque. Early feedback from staff and patients indicated that the kiosk was being used and was helping more people to access appropriate support.

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. They were also involved in decisions about their care.

The service had an exceptional understanding of the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity. We found the practice prioritised the diverse health and care needs of their local community.

We saw the practice worked in partnership with other services to meet the needs of its patient population. The practice had tailored its services to meet the diverse needs of its community. For example, participating in research programmes pertinent to the patient population and building relationships with community groups to promote the take up of screening programmes. This was most evidenced by the in-reach work they had taken to support patients with increasing cancer screening uptake, flu vaccinations and annual health checks.

We received feedback from local leaders. They commented on the practice leaders demonstrating a clear and genuine commitment to engaging with the local community. They said they would continue to collaborate with the provider particularly “through future campaigns promoting NHS Health Checks, flu vaccinations, and reducing stigma and barriers around mental-health discussions within the community”. They said this represented a significant and welcome shift in trust and engagement. Evidence on the impact this integration had had for patients is referenced throughout the report.

The practice worked in partnership with other services to meet the needs of its patient population. A GP partner was the named GP for local care homes. They carried out weekly scheduled contacts. The provided supported a local care home they provided a service to, to improve continuity of care by enabling a trained and familiar care‑home clinician to undertake blood tests on‑site, reducing delays and strengthening integrated, person‑centred care. Feedback from this provision was extremely positive.

The practice mainly used a consistent group of six GP locums who were fully integrated into the team. Additional locums were only brought in when none of the regular clinicians could provide cover. During the assessment, no concerns were raised about continuity of care.

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

The practice had access to interpreter services, including British Sign Language. Some staff at the practice were multi-lingual. 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.

Complaints were managed in line with the practice’s policy. Learning from complaints was evident and staff were able to identify changes made because of patient feedback, including complaints.

The practice actively listened to people and involved them in shaping services. The PPG reported strong engagement and told us they felt well informed, fully included in discussions, and that their views were valued and used to influence developments. Both partners regularly attended PPG meetings, which members told us strengthened communication, visibility, and trust. PPG representatives described significant improvements under current leadership and said the practice responded effectively to the needs of its diverse community, ensuring minority groups were supported and encouraged to represent the group.

Evidence reviewed showed a clear culture of involving people and using feedback to drive ongoing improvement.

We found the practice had an ethos of supporting people who may face barriers to accessing care and took practical steps to ensure people received support in ways that worked for them.

The practice showed a strong commitment to supporting people who may face barriers to accessing care. The provider told us they tried to create as much capacity as possible and fill every appointment available. They reviewed capacity and demand, increased appointment availability, and proactively contacted patients when short‑notice slots were free so care could be delivered in ways that worked for them. They recognised that enhanced access services were located at other GP practices in the Primary Care Network (PCN) and that personal circumstances such as travel costs prevented some patients from using them. Enhanced Access (EA) GP servicesprovide NHS patients with pre-bookable, routine primary care appointments outside core, 8:00 AM–6:30 PM, weekday hours. Operated byPrimary Care Networks (PCNs), it offers evening (6:30 PM–8:00 PM) and Saturday (9:00 AM–5:00 PM) appointments, allowing access to GPs, nurses, and other health professionals for improved flexibility.To reduce this barrier, they worked with the PCN to make full use of ARRS roles and initiatives and prioritised freeing as much capacity as possible within their own practice during core hours Primary Care Networks (PCNs) are groups of local GP practices working together with community partners to provide integrated, proactive care, while the Additional Roles Reimbursement Scheme (ARRS) provides funding for PCNs to recruit a wider range of healthcare professionals—such as pharmacists, paramedics, and social prescribers—to increase capacity, improve patient access, and reduce GP workload

As part of this, they identified that pharmacy‑related queries were taking up a large share of GP triage time. Working with the PCN pharmacy team, they redesigned workflows, so these tasks went directly to pharmacy staff. Reception and telephony teams helped shape the process. This freed GP capacity for patients with acute clinical needs, improved task resolution times, and enabled more consistent, equitable access to the right professional. The change was being monitored collaboratively.

People could access the service to suit their needs for example online, in person and by telephone. Those requiring a longer appointment were provided with them. Support had been made available to patients to increase the uptake of the NHS App which had seen a steady uptake in usage.

Treatment rooms were available on ground and first floor. A lift was available but was out of action awaiting repair on the day of the site-visit. Ramped access and automatic door were in situ at the entrance.

In the NHS National GP Patient Survey results 2025 the practice performed better or equal to national averages in several areas concerning access, for example patients were positive about their overall experience, with 80% responding positively to this question, compared with 70% nationally. 93% responded positively to the question patients found reception and administration staff helpful.

However, the practice performed below the national average in respect of contacting the practice by telephone and the website. For example, 41% of patients found it easy to get through to this GP practice by phone compared with 53% nationally and 44% of patients found it easy to contact this GP practice using their website compared with 51% nationally.

In response to the National GP Patient Survey data and from feedback from members of the community and other organisations the provider had identified changes to improve access to the service. The providers demonstrated a proactive and structured approach to improving equitable access, ensuring where possible people could access the care, support and treatment they needed when they needed it. Evidence of changes made through their enrolment in the GPIP programme (TheGeneral Practice Improvement Programme (GPIP)is an NHS England initiative designed to help GP surgeries and Primary Care Networks (PCNs) modernise how they work to improve patient experience and reduce staff pressure) and collaboration with others were seen, including total triage, NHS-approved digital communication platform messaging availability extended from standard hours to 6:30am–6:30pm, significantly increasing patient access and flexibility, multiple access routes, PCN-level chronic disease home visit team and increased same‑day appointment capacity. Unverified provider‑supplied survey data indicated early positive impact, with 72.6% of patients reporting improved access, 65.6% reporting shorter call‑waiting times, and 76.3% feeling they received a timely response. The practice has progressed toward implementation of AI-supported telephony to address persistent access challenges and call waiting times. At the time of the site-visit implementation was in 3 – 4 weeks. This change had been communicated with patients and was evident on social media platforms.

All the feedback received direct to CQC was positive about access. They described the significant difference that had been made in the last 12 months. Feedback from the Friends and Family Test over the past 12 months, as provided by the provider, was mostly positive. Some of the negative feedback related to lengthy delays when waiting for appointments, with patients reporting that clinics were overrunning. The provider was aware of this and evidenced that appropriate action had been taken to address the concerns being raised and as evidence throughout the report had systems in place to regularly monitor, review and adjust access arrangements.

Staff and leaders were innovative in how they listened to information about people who are most likely to experience inequality in experience or outcomes. Staff and leaders actively used this information with an aim to provide exceptionally tailored care, support and treatment in response to this. We found leaders actively prevented discrimination and inequality that could disadvantage often marginalised groups. They acknowledged that further work was required to reach out to all community groups and had plans for this.

Feedback provided by people using the service, both to the provider as well as to 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.

There were several examples of action the practice had taken or where they have collaborated with others over the last 12 months to help meet the needs of those most at risk of discrimination and inequality in access and outcomes from health and care. For example: The provider had identified reactive scheduling of chronic disease home visits led to inconsistent review timings for housebound patients. The provider identified this issue and proposed a PCN‑level home‑visit team to deliver timely, standardised reviews which was implemented. The provider informed us that systems were now in place to review those patients on the home visit list to ensure it was up to date and accurate.

The PCN identified gaps in dementia support and, through shared learning across practices, agreed to reinstate specialist input via the appointment of an Admiral Nurse. This has strengthened continuity of care, improved timely access to specialist expertise, and enhanced support for families, leading to more equitable experiences and outcomes for people living with dementia and for patients within the practice.

Following an emergency department (ED) attendance audit that identified two high‑attending patients, the practice worked with the Community Matron’s Team to carry out joint case discussions and improve care planning. This resulted in a 47% annual reduction in emergency service use and an 85% reduction in ED attendances for this cohort.

Providers worked with the local mosque to understand cultural and practical barriers affecting how people accessing healthcare. The provider told us they used this learning to make health information more culturally sensitive and to deliver outreach in more accessible ways, helping improve trust, engagement, and equity of access for communities who may face barriers to traditional NHS service

Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and Travellers. Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to the internet.

National GP Patient Survey data was extremely positive, and above national averages, about confidence and trust in the healthcare professional they saw or spoke to.

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.