Two Rivers Medical Centre

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. This key question continued to be rated as good. The practice worked to reduce health and care inequalities. People were involved in decisions about their care and treatment and were provided with advice and support in a way they could understand, which included planning for the future. Improvements were being made to the governance arrangements of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) and ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) decisions. People knew how to give feedback and practice staff acted on this, which included continuing to improve access to appointments.

This service scored 68 (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 majority of feedback from people using the service was positive and during long term condition reviews people felt staff understood their individual needs. Care home representatives told us care and treatment was based on people’s individual needs and preferences. People, and where appropriate, family members and carers were involved in care and treatment decisions.

The practice had arrangements in place to support person centred care. For example, people who were due a long-term condition review could book their appointment online or by telephone on a date and time to suit them. Clinical staff told us during consultations they discussed relevant information, listened to people’s concerns and expectations, identified peoples’ needs and preferences and agreed a plan of care together which suited the person.

Care plans reflected people’s physical, mental, emotional, and social needs, 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.
The practice complied with legal equality and human rights requirements, which included avoiding discrimination and having regard for the needs of people with different protected characteristics. The practice had information available in alternative formats and arrangements were in place to support people who had a sensory impairment.

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.

Practice leaders told us people were mainly registered with a GP Partner, although some people were registered with a salaried GP. This enabled people’s GP to maintain oversight of their care and treatment and effectively manage the workload and retention of salaried GPs. Staff told us that people could request to see a GP of their choice or choose to see the same GP for follow up, although there may be a longer wait. Systems were in place to ensure people were seen by an appropriate clinician if needed. Clinicians could request to follow up people, based on their clinical needs to provide continuity of care. To maximise capacity for appointments, the requests were reviewed by a ‘follow up request group’ before being agreed and actioned. Arrangements were in place to ensure continuity of clinician for people who lived in a care home.

Leaders had a good understanding of the needs of the local population and provided a range of services at the practice which included for example, a Women’s Health Advanced Practitioner, a Paediatric Nurse Practitioner and a GP Skin Specialist. The practice supported the local children’s hospice and provided primary care services to inpatients, parents or carers during their stay. They planned COVID and flu vaccination clinics and visited people who were housebound or who lived in a care home to administer these.

Practice staff had a range of services and organisations they signposted and referred people to, which included mental health practitioners. Once a month, the practice hosted ‘Key to Care Drop-in sessions’ which were delivered by Home Instead who offered free one-on-one support and information for those living with dementia, worried about their memory or for carers supporting someone with dementia.

We received positive feedback from partners in relation to how practice staff worked with them to increase the availability and provision of services.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. We did not receive any concerns from people regarding not being able to access appropriate, accurate and up-to-date information in a way that suited their needs.

Staff told us information was available to people in different formats, and it would be highlighted on the person’s record if they had any communication or accessibility needs. Some staff gave examples of information they had provided to people to aid their understanding of care and treatment options. An example was giving people the opportunity to look at what equipment was being used for a procedure.

Some staff were able to speak other languages so appointments could be booked with those clinicians, if they were available. Interpreter services were available for those people whose first language was not English, and for people with a hearing impairment. Staff told us they were aware of the arrangements in place to book an interpreter.

The practice shared a link on their website to the NHS accessible standards information which included how people can make the practice aware of their specific communication needs. Notices in the practice advised people that information was available in other languages on request. Easy read and pictorial information was available around the practice. Information was available for people on 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.

People who provided feedback had no specific views or concerns in this area. Care home representatives told us they were appropriately involved, were listened to when they gave feedback and knew the processes in place to raise a concern if appropriate. Representatives from the Patient Participation Group told us their views were listened to and gave examples of changes made following people’s feedback.

Complaints information was available in the practice and on the practice website. The practice had a GP lead for complaints. The practice had received 51 complaints in 2024, with themes regarding access, access by telephone and communication. We reviewed a sample of complaints and found they had been managed in line with the practice’s policy. Complaints had been acknowledged, investigated in a timely way, people were given an apology and actions taken in response were shared. People were advised of the contact details of the Parliamentary Health Service Ombudsman if they wanted to escalate their complaint.Learning from complaints was evident, for example, a clinician was supported to listen back to and reflect on their consultation, and tuning forks, used to identify hearing loss, were now available in the practice. The practice also recorded, reviewed and shared positive feedback regarding staff, in a ‘praise’ channel on teams which included feedback from people who used the practice.

The practice undertook a survey of 40 people in the reception queue or in the waiting room in January 2025. The area of lowest satisfaction was time taken to get through by phone. Satisfaction rates with the friendliness and helpfulness of reception staff were significantly higher. In response, the practice added information to the television screen, check in screen and at the check in desk in the waiting room if a clinician was running late.

The service did not always make sure that people could access the care, support and treatment they needed when they needed it. Practice leaders were aware of this, and further improvements were planned.

Feedback we received from people was mixed regarding access. Some people found improvements had been made to access by using the online access system and also with the call back facility on the new telephone system. However, some people still did not find accessing an appointment easy, particularly by telephone. There was positive feedback regarding access for children and appointments with GP Registrars. Care home representatives were generally satisfied with appointment arrangements. Some received a weekly call to identify if any people needed to be assessed or reviewed, which was arranged, and others also received a regular weekly visit. Additional visits for made for people with urgent needs. A separate telephone line was available for requests to be made.

We reviewed the National GP Patient Survey data, published in July 2024. One indicator for access, describe your experience of contacting your GP practice on this occasion, was in line with the England average. Another indicator, how easy or difficult is it to contact your GP practice on the telephone, was below the England average.

In response to the National GP Patient Survey data and people’s feedback regarding access by telephone, improvements continued to be made. In October 2024, the practice changed their telephone system which enable people to request a call back. Practice leaders told us they regularly monitored access data and were aware of continued feedback from people regarding difficulty accessing the practice by telephone. The practice were in the process of moving to a total call triage system from 12 May 2025 to further improve equity of access. This is a system where every person contacting the practice will advise on the reason for contact and will be triaged to decide the best response. They were currently communicating with people, including the Patient Participation Group (PPG) members, and training practice staff. Members of the PPG were due to receive some training on the system, so they were able to advise and support people to use the system. However, at the time of this assessment these processes and arrangements were not in place or sufficiently embedded to be able to demonstrate improvement or positive impact for people who used the service.

Appointments were available on 4 weekdays, between 7:30am to 6:30pm, until 7:30pm on one weekday, and on Saturdays from 9am to 1pm. Extended hours appointments were available for people who worked during the day and were available with a range of clinicians which included GPs. Appointments could be made in person, via telephone or online. Staff told us people with the most urgent needs had their care and treatment prioritised and were booked into an appointment with a clinician. If all appointments had been taken, urgent requests were reviewed by a duty GP and responded to as appropriate. The practice was responsive to the needs of people who were too ill or physically incapable of travelling to the practice and offered home visits. The practice had a duty GP available every day for advice and support as necessary.

Staff and leaders actively listened to information about people who were most likely to experience in equality in experience or outcomes and tailored their care, support and treatment in response to this. Practice leaders knew the demographics of their patient population which included for example, age, diversity, deprivation and economic factors which impacted the health needs of their population.

We received no specific feedback from people regarding their experiences for this quality statement. Care home representatives told us people received weekly visits with continuity of staff which had improved outcomes for people.

Leaders and staff sought ways to address any barriers to improving people’s experience and outcomes and worked with local organisations to address any local health inequalities. Staff treated people equally and without discrimination. Staff told us they respected and appreciated people's backgrounds and cultural values, and they had received training in equality and diversity, and learning disability and autism awareness. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes.

Processes were in place to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people, asylum seekers and refugees and Travellers. Arrangements were in place for Care Coordinators to engage with people who were more likely to experience inequalities in health and outcomes. This was usually by telephone with escalation arrangements to a GP if repeated contact attempts were unsuccessful.

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. However, improvements were being made to the governance arrangements of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) and ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) decisions, which needed to be embedded.

The practice had a newly written DNACPR/ReSPECT policy, which included arrangements, for example, for decision making, documentation, sharing information, reviewing decisions and audit. We reviewed the records of 2 people who had a DNACPR and found alerts were in place on both records, so this information was easily available to other health care professionals. The GP Partner advised a copy of the form had not been scanned onto these people’s record, and was kept with the person/care home.

Practice leaders told us they were in the process of reviewing their records with people, to ensure all people with a DNACPR or ReSPECT were correctly coded on their system. They planned to review people who had made their decision over 1 year ago, planned to have pop up messages on the system to alert staff to this and planned to undertake regular audits to ensure coding and decisions were reviewed and up to date. They had prioritised people who lived in a care home or were housebound. For example, information submitted by the provider before the site visit, identified 48 people who lived in a care home who had a DNACPR and an alert on the system, but this information had not been coded on the system. This included 24 people who had recently moved into a care home. Following the site visit, we requested an update and were advised the records of 17 people had been updated. The names of 31 people who needed follow up had been passed to the relevant clinicians to be followed up on their next visit. For people who had recently moved into a care home, this included a clinician or care coordinator who worked with them, to ensure their decisions were reviewed and recorded and a ReSPECT agreed, if appropriate.

We received positive feedback from people, which included care home representatives, with how practice staff supported people to plan for their future and in meeting people’s end of life care needs. All people over 75 years of age were coded according to their frailty score and were encouraged to have a ReSPECT.

The practice maintained a list of people with palliative care needs and people at the end of their life. They had systems in place to support and review people, which included people who lived in a care home, those who were housebound, and worked in partnership with other organisations. For example, one of the large nursing homes where people were registered at the practice, received a weekly ward round solely for people at the end of their life. The practice also visited people in their own home, when appropriate. Staff referred to the ‘Compassionate Companions’ service, who provided practical emotional and spiritual support to people in the local area who were at end of life, and their loved ones.