Causeway 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

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination.

At our last assessment, 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.

The practice told us that they regularly involved patients in planning and making shared decisions about their care and treatment that met their needs. Staff had been trained in equality and diversity, consent, deprivation of liberty safeguarding and mental capacity.

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.

Patient satisfaction scores in the GP National Patient Survey were above local and national averages, particularly in areas relating to patient-centred care. For example, 73% of people said the healthcare professional they saw or spoke to was good at considering their mental wellbeing during their last general practice appointment. This was in line with the local average of 71% and the national average of 74%.

A review of clinical records confirmed that patients were supported in understanding their conditions and were actively involved in planning and making decisions about their care.

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 practice was an accredited armed forces veteran friendly practice and was also registered as a safe surgery. Staff had been trained in recognising the barriers to healthcare that exist, particularly for migrants in vulnerable circumstances.

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. Staff at the practice spoke a range of languages which provided support to people within the local community.

The practice website included useful information on health awareness and promotion. Information and resources were available for patients to support them to understand how to access services.

There were systems in place to support patients to access treatment, and patient records were held in line with guidance and requirements. We found the practice complied with the Accessible Information Standard (AIS) and that information about people collected and shared was in line with data protection legislation requirements. Patients were informed 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.

Information about how to complain was readily available and patients could make a complaint in person or via the practice website.

Feedback from the GP national patient survey demonstrated that 78% of patients said the healthcare professional they saw or spoke to was good at listening to them during their last general practice appointment. This was below the local average of 84% and the national average of 87%.

We spoke with patients on the day of the onsite assessment and received positive feedback on the care and treatment people received.

There was a patient participation group (PPG), in place and meetings were held every 6 months. We spoke with 1 member of the group who told us they were encouraging patients to join the group. Staff and the leadership team were approachable and kept the group up to date with changes.

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 practice told us they obtained feedback from various sources such as complaints and via informal feedback from patients. The GP national patient survey showed 52% of respondents found it easy to get through to the provider by phone. This was in line with the local average of 48% and the national average of 53%. Patients could access appointments by phone, online and face to face. Patients who had a request for an emergency appointment were seen the same day. Feedback from patients we spoke with on the day of the assessment highlighted the good service they received. The practice website provided information for patients regarding how to book an appointment. Feedback from staff demonstrated people in vulnerable circumstances were able to register with the practice, including those with no fixed abode.

Feedback from the PPG was positive on accessing the practice and the availability of appointments. Patients told us how helpful staff were in dealing with their requests and how supportive and approachable the staff were.

Appointments with a GP were available throughout the week. Extended appointments were available for vulnerable people and those with a learning disability. The practice provided extended hours appointments one evening a week until 8pm. When the practice was closed patients were able to contact 111. The practice offered appointments from a variety of additional clinical staff for example nurses and a pharmacist. Pre-booked appointments were available on weekday evenings and on Saturday through an arrangement with other local GP practices.

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.

The provider complied with legal equality and human rights requirements, including avoiding discrimination, having regard to the needs of people with different protected characteristics and making reasonable adjustments to support equity in experience and outcomes, including meeting the Accessible Information Standard (AIS). We saw examples where the practice had removed barriers for improved patient experience. For example, the practice premises had a hearing loop in place and access to interpreters was available. We found the premises user friendly for people with a disability.

The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people. 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 with learning disabilities and poor mental health experienced additional care through annual reviews. People with dementia were referred to appropriate services where required.

People we spoke with on the day of assessment was positive about the services provided. 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. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes.

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.

Leaders understood the requirements of legislation when considering consent and decision making and had access to policies to support them. We were told that the practice held multidisciplinary meetings to share and discuss information relating to patient care and treatment, for example, those on the practice palliative care register.

There were systems in place to ensure staff kept up to date in training relating to the Mental Capacity Act and Deprivation of Liberty. We found that staff had completed the required training.

Our records review showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation.