Canberra Old Oak 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.

At our last assessment in November 2022, we rated this key question as Good. At this assessment, the rating remains the same.

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 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.

The team could describe examples of person-centred care, for example timing a home visit so a person could be discharged from specialist care immediately before a bank holiday.

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.

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, building relationships with community groups to promote the take up of screening programmes. There were established mechanisms for engaging with the community healthcare provider.

The service held regular multidisciplinary team meetings to review the cases of people with complex needs. It held a regular mental health multidisciplinary review. People with mental health needs that were not suitable for talking therapies had access to a mental health liaison worker at the practice who was funded by the primary care network.

The service engaged with the community to promote healthy lifestyles, for example, one of the healthcare assistants led a weekly walk.

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

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. 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.

The National GP Patient Survey (2025) results showed that 87% of respondents reported being involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. This was in line with local (90%) and national averages (91%).

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.

The service made sure that people could access the care, support and treatment they needed when they needed it. The service had made changes to the appointment booking system.

The service was contracted to provide a set number of appointments per week and could demonstrate that it was achieving this requirement. All appointment requests were ‘triaged’ by an experienced GP and allocated to members of the clinical team as clinically appropriate. Emergency appointments were available every day.

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. The service operated an online appointment service which could be accessed via an App. The service had switched to a different App following negative feedback about the previous system. This change had in turn led to critical feedback although the team were confident that this was improving as people became more familiar with the new system.

People could access the service to suit their needs for example online, in person and by telephone. The waiting and treatment rooms were located on the ground floor of the health centre which was fully accessible.

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

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. The service had a relatively young population and the team were keen to ensure that they did not inadvertently miss people who were also carers. The service had developed an action plan to identify and support carers including young carers. They had appointed a carers champion and reviewed the systems in place to identify carers, for example on registration or when contacting the service. They were in the process of organising additional training for staff and were planning an event to raise awareness about the support available.

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. Clinicians could describe how they adapted people’s care to take account of individual circumstances, for example, adapting treatment for people when they were observing Ramadan.

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.

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. The service carried out a regular audit to assess how well it had met people’s wishes in relation to their end-of-life care and death.