Edith Cavell 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 outstanding. At this assessment, the rating has changed to good.

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. They were also involved in 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. The service had undertaken numerous patient engagement events in the past year, with subjects including mental health and screening services. There were established mechanisms for engaging with the community healthcare provider.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. For example, the service had utilised artificial intelligence tools to provide videos explaining benefits of cervical screening in multiple languages.

Feedback from the National GP Patient Survey showed that 89% of patients felt the healthcare professional they saw had all the information they needed about them during their last appointment, which was in line with the local and national averages of 91% and 92%, respectively.

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.

There were processes in place informing patients on how to make a complaint. We reviewed a sample of complaints from the past year and saw that they 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.

National patient survey feedback (undertaken in winter 2024/5 and published in summer 2025) indicated that patients did not always find it easy to access appointments. For example,41% found it easy to get through to this GP practice by phone, compared the average locally and nationally of 53%. 53% describe their experience of contacting their GP practice as good compared the average locally of 68% and nationally of 70%.

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. For example, the practice had continued to develop the total triage model which allowed for more online enquiries, and ensured easier access to clinical triage. The service had undertaken its own internal surveys following implementation of these systems which showed an increase of 7% in ease of access to appointments. People could access the service to suit their needs for example online, in person and by telephone.

The service was able to demonstrate that it offered among the highest number of appointments in the borough (per patient). There were also measures in place to prioritise patients who were in the highest risk groups.

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.

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, 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. 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.

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.