Sheepcot 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 has been rated as Requires Improvement. The service was in breach of legal Regulation 17(1) and 17(2), Good Governance, of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 61 (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. For example, care plans would include communication needs, accessibility requirements and if any additional support was needed when making an appointment. They were also involved in decisions about their care. The 2024 national GP patient survey showed the practice was in line with local and national averages for involving people in their care and decision making. The practice patient participation group were mostly positive about the practice and told us they wanted to become more involved with supporting the provider to ease their workload.

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. 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.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. As the practice did not formally collate patient information, there was no documented evidence of actions taken, although patient feedback told us that changes were made. The practice acknowledged that a formal approach to recording patient feedback was required. Information to promote the take up of screening and immunisation programmes was available in a range of languages, such as polish. The practice had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard which showed how patients were informed to how to access their care records.

The service did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment, and support. They did not always involve people in decisions about their care or tell them what had changed as a result. We saw complaints were not always managed in line with the practice’s policy. For example, we sampled complaint responses and saw they did not always include the escalation details for the Parliamentary Health Service Ombudsman. Learning from complaints was seen, however, there was a lack of governance toward documenting and maintaining reviews of action plans. Staff were not all able to identify changes made as a result of patient feedback. Patients were able to make complaints, in person, via the website and in email form. Patient feedback told us that they lacked assurance of a complaint made being handled in a timely manner. Additionally, the provider did not have a formal tracker of complaints and it was unclear how many had been handled satisfactory within the previous 12 months.

The service did not make sure that people could access the care, support and treatment they needed when they needed it. In response to the 2024 National GP Patient Survey data and from feedback from members of the community the provider had identified changes to improve access to the service. People’s feedback told us that despite these changes, they could not easily access the service to make appointments and reported a poor experience of the practice. The provider had implemented new telephone systems in order to include a call back function. For patients who found it difficult to complete online access, the reception staff would complete the forms with the person if they telephoned or visited the practice. Treatment rooms were available on the ground floor and an automatic door had been fitted to the entrance.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this. Feedback provided by people using the service, both to the provider as well as to CQC, was mixed. The 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 was no measurable data available to monitor outcomes. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experiences and outcomes. The provider did not have adequate governance processes to monitor and improve access; for example, there was no formalised approach to monitor access effectively. The staff would monitor the telephone calls coming in and adjust staffing as required, however, in busy periods, the management team would support staff. The provider did ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and Travellers. Staff used registers to capture and review feedback from people using the service, including those who did not speak English or have access to the Internet. The provider recognised the need to strengthen their approach to documenting equity in experience and outcomes in a more formalised manner.

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, such as palliative care and community teams.