Baddeley Green 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

People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. However, we found verbal complaint monitoring and trend analysis was not auditable. Following this feedback the provider immediately put appropriate measures in place. The service was easy to access and worked to eliminate discrimination. 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.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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.

A Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form is a document that records a person's preferences for emergency care and treatment. The practices Lead GP ensured these were regularly reviewed in line with best practice guidance.

Staff told us they used decision aids, such as leaflets, videos, or online tools, to help patients understand their options and make informed choices. Patients with poor mobility were booked to attend the main practice rather than the annex which had stairs to navigate. Learning disability and autism patients, dependant on their bespoke needs, received information in easy read or pictorial formats for their annual health reviews and care plans.

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, learning disability and autism patients building up rapport and professional trust relationships. There were established mechanisms for engaging with the community healthcare provider.

The leadership found continuity of care increased patient satisfaction and patient experience, which was further evidenced in the National GP Survey results data. They ensured the same group of clinicians reviewed patients when able and booked back with the same GP for their follow up and the reception team supported patients to book in with a doctor they had previously seen. The practice supported peopleconsidering gender transitioning including referrals. Once on specific medicines the practice supported the blood monitoring tests as required.

Information to promote the take up of screening and immunisation programmes was available in a range of languages. The practice had access to interpreter services, including British Sign Language (BSL). Information provided by the service met the Accessible Information Standard (AIS). Patients were informed as to how to access their care records. Learning disability and autism patients were provided information as appropriate in pictorial easy read formats.

The practice took account of their patient demographic in respect of booking of appointments as many preferred to use the telephone and attend face to face. Patients who maybe digitally excluded were offered information in other formats such as letters.

The National GP Survey results 2024, found 94% of the survey respondents knew what the next step would be after contacting the practice, when compared to the Integrated Care System (ICS) result of, 84% and National result of, 83%. 98% knew what the next step would be within two days of contacting the practice, when compared to the ICS result of 94% and National result of, 93%.

Leadership maintained a complaints matrix divided into sections such as, near miss, adverse incident and good practice. The matrix contained links to the original complaint form which could be accessed on line to review. We saw complaints were discussed at practice and clinical meetings. Processes were put in place to mitigate the risk of reoccurrence. Verbal complaints were dealt with, in general by the lead GP, who contacted the patient and records made of this contact in the consult notes. We found that verbal complaints were not collated. Collating these complaints would assist in the early identification of any trends. Collating complaints can support the early identification of emerging trends. In response to feedback from the Care Quality Commission, the leadership team updated the practice website to reflect changes in how verbal complaints are handled. They also revised the complaints policy and leaflet to include a clear timeframe for when patients should expect a response. Additionally, an interim letter is now issued to complainants, providing a rationale if there is a delay in concluding the complaint investigation.

Learning from complaints was evident and staff were able to identify changes made as a result of patient feedback, including complaints.

In response to the National GP Patient Survey data and 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 and offered a Saturday service for their annual reviews bi-annually. People could access the service to suit their needs for example online, in person and by telephone. Treatment rooms were available on the ground floor at the main practice location and automatic doors to the entrance. These supported easier access for patients, particularly those with mobility needs. Patients with poor mobility were booked appointments in the main building rather than the annex building which had stairs to navigate.

There was disabled car parking though car parking availability overall was limited.

Leaders ensured patients were kept informed of any changes at the practice using the practices Facebook page and website. The Care Quality Commission (CQC) Give Feedback on Care link, had been added to the practice website for patient feedback and we were in receipt of positive patient feedback.

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. The practice served an older patient population, and the provider made a conscious decision to have a higher proportion of GP appointments, opposed to allied health professional appointments.

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, 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. 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.

The National GP Survey results 2024, found 85% of the survey respondents found it easy to get through to this GP practice by phone, when compared with the Integrated Care System (ICS) result of, 52% and National result of, 50%. 68% of the survey respondents found it easy to contact the practice using their website, when comparted with the ICS result of, 44% and National result of, 48%. 95% of the survey respondents described their overall experience of this GP practice as good, when compared with the ICS result of, 76% and National result of, 74%.

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. Staff had completed training in the Mental Capacity Act and Deprivation of Liberty Safeguards and consent.