Favell Plus 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 assessed all the quality statements from this key question. We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination. The practice complied with legal equality and human rights requirements. People were encouraged to give feedback which leaders used along with other evidence to improve services. People could access care in ways that met their personal circumstances and protected equality characteristics. People, carers, and staff could easily access information and advice. We found some systems needed improvement, specifically those relating to supporting patients to plan for their future care. This key question has been rated as Good.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice 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. People with caring responsibilities were identified and supported. People had access to a range of healthcare professionals so they could access the most appropriate 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, the practice was actively involved in their local Primary Care Network (PCN), where they worked with other practices to improve the local health delivery. There were established mechanisms for engaging with the community healthcare providers. Information was available on a range of services people could access or self-refer to, which included carer support, drug and alcohol, and mental health services.

The practice supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. Staff told us information was available to patients in their reception area and on the practice's website. At the start of our assessment, we found some areas of the practice website were out of date and some information was missing. For example, information on how to make a complaint was not available on the website. The practice leadership team were prompt to respond and updated the website during our assessment. The practice website contained details on how to make an appointment, the services available, and resources.

The practice had access to interpreter services, including British Sign Language. They would highlight in patients' records if they had any communication or accessibility needs; information which staff gathered when a patient registered and opportunistically. Information provided by the practice met the Accessible Information Standard. Patients were informed as to how to access their care records. A hearing loop was available. Longer appointments were available to be booked if staff needed to use a translator, for neurodiverse people or people with a Learning Disability.

The practice was good at enabling people to share feedback, 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.

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 people’s feedback, including complaints.

The service made sure that people could access the care, support and treatment they needed when they needed it. The practice was open from 8am to 6.30pm Monday to Friday. In addition, the practice participated in the Primary Care Network (PCN) extended access programme, providing regular evening clinics from 6.30pm to 8pm other practice locations locally.

Results of the National GP Patient Survey 2025 were below average in relation to access. 59% of patients had a positive experience of contacting the practice compared to the national average of 70%. 33% of patients responded positively to how easy it was to contact the practice on the phone, compared to the average of 53%. Practice leaders advised proactive steps had been taken to improve telephone access since April 2025. This included substantial increases on the number of staff answering telephones during peak periods. Unverified telephone data shared with us demonstrated that these improvements were having a positive impact on telephone access. For example, between April and October 2025, the number of abandoned calls had dropped by approximately 50%. People could access the service to suit their needs for example online, in person and by telephone. Staff advised many patients still preferred to telephone the practice.

Staff and leaders actively listened to information about people who were 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.

However, our review of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms found information on these was not always readily available. (The ReSPECT form is a tool for documenting patient preferences regarding care at the end of life, ensuring that their wishes are respected in emergency situations). Records we reviewed appeared incomplete. We discussed this with the leadership team who advised this was an area in need of improvement and there had been some confusion on the use of digital read coding in the practice’s computer system to readily identify these patients. During our assessment leaders developed a system to code patients as soon as ReSPECT forms were completed in the future. Immediately following our assessment, the practice advised they were prioritising work to ensure consistency in record keeping for these patients which included a full review of records for all patients affected.