Potterells Medical Centre

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• 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

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.

We saw examples of patient centred care across all its population groups. This included their university students including those with long term conditions identified on registration. For students newly registered with the practice, those with existing health conditions, including students with mental health conditions which made up a large population of the practice were offered a welcome appointment with the GP to ensure that their regular medicines and follow-up were all in place. They booked their appointments just 48 hours ahead as this proved to be what the students preferred and it significantly reduced the rate of non-attendance.

We also saw patient centred care for care home residents where the Primary Care Network (PCN) employed a clinical pharmacist who was responsible for medicines optimisation, including medication reviews, medicines reconciliation and monitoring. They worked closely with GPs, co-ordinated monthly multi-disciplinary team meetings, supported vaccination consent processes and contributed to wider care home team functions.

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 mostly involved in planning for and decisions about their care needs.

We sought patient feedback as part of the assessment and received 242 responses, of which 228 were positive and 14 were negative. The high volume of positive feedback compared to the small number of negative responses indicated overall high patient satisfaction with the quality of care provided.

On assessment we observed different coloured doors to the different rooms in the practice, which were used to help differentiate rooms, supporting wayfinding for staff and patients.

Positive feedback consistently highlighted person-centred care, with patients reporting that staff were attentive, supportive, and followed up their care until satisfactory outcomes were achieved. Patients described high levels of confidence in the practice’s management of complex conditions and expressed strong satisfaction with the care provided, with some stating they felt fortunate to be registered with the service and did not wish to move.

When we reviewed the 2025 GP National patient survey, we saw that 74% of patients responded positively to the overall experience of their GP practice and this was in line with the national average of 75%.

The service had a good understanding of the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity. For example, cancer patients benefited from a cancer care co-ordinator whose role was to follow up cancer patients and ensure they received their appointment, including new cancer patients. Three-monthly cancers reviews were carried out via telephone follow ups.

The COPD and asthma GP lead described a proactive approach to identifying and responding to patient needs. This included contacting patients to arrange annual reviews or coordinating with the navigation team to support those unable to use digital systems. They were also involved in managing patients with complex needs and providing oversight and support to nursing staff delivering long-term condition care, helping ensure care provision was tailored to individual patient requirements and continuity was maintained.

We saw the practice worked with other services to meet the needs of its patient population; for example, hospice staff and district nurses. Staff told us they worked to support people moving between services and ensuring there was continuity of care when this happened. Staff responsible for arranging routine monitoring were able to describe the recall system. They made referrals to the community nursing teams where required.

They provided care to approximately 112 care home residents and were part of a 4-practice Primary Care Network (PCN). They recruited staff who they shared with the rest of the PCN. There were established mechanisms for engaging with the community healthcare provider as well as health visitors and school nurses.

University students also received effective provision of care from the practice. The practice held monthly multidisciplinary meetings with the university’s wellbeing team, involving GPs and wellbeing staff, to discuss vulnerable students with mental health needs. These meetings supported coordinated, proactive care provision, enabling identification of risks and the implementation of additional support mechanisms tailored to meet students’ needs. Patients also benefited from GPs with special interests in areas such as diabetes, palliative and dementia care.

Feedback from patients was mostly positive about their care; they told us the care provision at the practice exceeded their expectations and most of the patients felt the standard of care provided by the practice was nothing short of excellent. There was a small amount of less positive patient feedback regarding this section. A patient reported seeing multiple GPs over an extended period, with repeated prescribing and agreed plans for referral not actioned, resulting in delayed access to a specialist service.

The practice also worked in collaboration with the integrated care board, a system that brought together social care providers, local government, the NHS, community organisations and other partners to improve the lives of people living and working in their area. The integrated care board reported good engagement with the practice. Data provided by the integrated care board showed there was a 4.1% increase of patients registering with the practice over the last 12 months.

The service generally supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. However, monitoring was required in some areas. We found patients had access to information in different languages via their practice website, including a google translate option.

The practice provided patient information through leaflets with QR codes, available in multiple languages to meet the needs of a diverse population, including a large university cohort. Materials were tailored to prevalent student groups, such as Bengali and Nigerian communities. Language and communication needs were routinely considered at the point of booking. However, we found a senior member of staff was not aware of the language services provision at the university site.

New patients had access to a patient leaflet and were informed as to how to access their care records. The practice did not have an Accessible Information Standard policy; however, we saw evidence that they complied with the requirements of this standard. Their practice website displayed a disability access policy, providing information on how the service supported patients with additional needs, including those who were deaf or visually impaired.

Patients could also access sign language services. Patients with hearing difficulties were also encouraged to inform the practice so that an alert could be added to their medical record, enabling staff to provide appropriate support, including personally collecting them from the waiting area to ensure safe and effective communication. A hearing loop was also available at both the main and university sites; however, we observed the loop at the main practice site was not plugged in, indicating a need for monitoring to ensure it is consistently operational and accessible for patients with hearing needs.

At the start of each academic term, the practice employed additional staff to support students in the registration area, providing information on how the NHS operates and assisting them to register with the medical centre.

The practice also provided targeted support to international university students unfamiliar with the UK health system. This included providing clear guidance to help their student population access services appropriately and manage expectations; for example, explaining that home visits were not routinely provided for minor illnesses such as colds, clarifying the difference between GP and dental services when patients presented with dental concerns, as well as advising on prescription charges where the students were unaware of associated costs.

Patient feedback received by CQC showed a small number of patients reported a lack of proactive communication regarding test results, noting they were required to check results independently online. For example, a patient stated they had to log in to see if their test results were available and only then determine whether follow-up was needed. This would likely disadvantage patients without digital access and indicates a need to improve follow-up processes and patient communication. Positive feedback highlighted compassionate, patient-centred care, with patients reporting they did not feel rushed, felt fully informed about next steps, and that their concerns were taken seriously with appropriate follow-up and referral where needed.

The PPG provided feedback and reported receiving regular updates through meetings, the practice website, emails, and word of mouth. They described positive communication about changes, including staffing updates and service developments.

We saw evidence that the service enabled people to share feedback and ideas, or raise complaints about their care, treatment and support via various channels such as the Friends and Family Test (FFT), the practice website and suggestion box. We were not assured the systems and processes in place were effective enough to ensure this was consistently applied within the practice, as we found gaps in the management of complaints. The practice also carried out their own internal surveys.

The practice had an active Patient Participation Group (PPG) who contributed regular patient insight through ongoing engagement with the practice. Patients were also able to raise concerns verbally and these were often acknowledged and resolved promptly at the point of contact; however, they were not consistently recorded, limiting oversight and audit trail.

There was a complaints procedure and complaints leaflet that provided people with information on how to complain and how to escalate their concerns to CQC if they wanted to share their concerns. Complaints were managed in line with the practice policy and they were discussed at monthly meetings to which all staff were invited, to support learning and improvement.

While the practice told us that learning from complaints was discussed within meetings, there was limited evidence to demonstrate how this learning was consistently shared with the wider team, as we were not provided with meeting minutes where complaints were discussed. Staff told us responsibility for complaints largely sat with the practice manager, reducing assurance that all staff were fully engaged in learning and making improvements to their day-to-day practice. This was consistent with feedback from at least 3 non-clinical staff who told us they were not made aware of complaints regarding the practice and could not describe any resulting improvements.

However, most staff demonstrated awareness of complaints and were able to describe learning. This was consistent with assessment findings, where some changes had been implemented because of complaints; for example, feedback from a patient who felt they were not being listened to led to reinforcement with staff on recognising, recording and taking ownership of all concerns.

The practice also reported a shift in complaint themes from reception-related issues to more individual staff interactions, with a more analytical approach adopted to identify underlying causes. For example, a complaint relating to medicines change without patient knowledge was discussed. The change had been prompted by their prescribing support software which identified clinically appropriate, cost‑effective alternatives; however, the clinician had not informed the patient. As a result, clinicians were reminded to communicate any prescribing changes to patients and provide a clear rationale.

At the university site, feedback including complaints was predominantly related to access to convenient appointment times and differing expectations of NHS services among the student population. The practice told us some students requested appointments for minor issues, such as cuts requiring simple first aid, or asked for investigations that were not clinically indicated, including full body scans. Staff provided clear explanations to help students understand appropriate use of NHS services, with concerns often resolved informally by the administrative team and practice staff.

The practice told us they had received 9 complaints in the previous 12 months; however, our review of the complaints log identified 12 complaints. We reviewed a sample of 5 complaints and found these were appropriately investigated, with apologies provided where required and some evidence of learning used to drive improvement. Escalation information was included in 2 of the 5 responses reviewed and 1 complaint was resolved through direct telephone contact with the patient.

The practice also published their monthly FFT results on their website, and we saw consistently positive feedback from the FFT results, where 124 out of 127 respondents rated the service as good or very good, 2 responses were neutral and only 1 patient rated the service as poor. The practice also told us patients frequently expressed appreciation for the care provided, with some reporting they felt fortunate to be registered with the service and this was consistent with feedback we received prior to the assessment. The practice told us that they would consider targeting their FFT results for their student population in the future.

Patient survey results showed 87% rated listening as good, in line with the national average, indicating a positive patient experience.

The practice also analysed their national GP patient survey results for 2025 and we saw evidence they involved people in decisions about their care and told them what had changed as a result. A member of the PPG told us the practice responded effectively to feedback shared through the group.

Positive patient feedback was shared at the practice’s monthly training events. Staff told us that feedback, including when individual staff members were mentioned by name, was shared with the wider team. This supported staff morale and encouraged a positive and reflective culture. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service.

The service made sure that people could access the care, support and treatment they needed when they needed it. The practice offered a range of appointment types including book on the day, telephone consultations and advance appointments. Out of hours services are provided by NHS 111. The practice told us clinicians worked across both the main site and the university branch site.

Services provided included long-term condition management, sexual health screening and immunisations, minor operations, child health management and disease screening. The practice tried to encourage patients to see the pharmacist first to enable the management of minor concerns and escalation to the practice if necessary.

We saw evidence that telephone access at the practice was good. The 2025 national GP patient survey results showed 62% of patients responded positively to how easy it was to contact their GP practice on the phone, which was higher than the expected average of 53%. Survey results also showed that 72% of patients responded positively to the overall experience of contacting their GP practice, which was higher than the expected average of 70%. The practice told us these positive outcomes were a result of responsive service delivery and effective joint engagement with their Patient Participation Group (PPG). They had implemented changes to their telephone system, introducing a digital callback function well ahead of wider system funding, to improve patient access and responsiveness.

The practice also implemented the total triage model, referred to as ‘Modern Access’, in February 2025, in line with national guidance to improve access and manage patient demand following a period of planning and preparation. Preparation commenced 6 months prior and included visiting other practices to see this model in action. Total triage aimed to improve continuity of care and especially met the needs of the student population, particularly those more comfortable with digital access. The system enabled greater flexibility in managing appointment capacity, preferred clinician, balancing same-day and future appointments and adjusting appointment length based on clinical need.

The practice had initiated a trial in October 2025 to further improve patient access, which included 2 GPs and an administrative support buddy role to review incoming triage requests. A second GP was made available during the first hour of the afternoon and triage activity was extended from 5.30pm to 6.30pm to align with the final appointment time. The practice reported this approach was manageable, with patients redirected to out-of-hours services after this time.

The practice continued to offer flexible access alongside its total triage model, with patients able to attend in person or contact the practice by telephone, particularly for non-clinical requests. Reception staff also supported patients who were unable to complete online forms. The provider reported that access remained good and that the total triage system had been implemented successfully; however, patient feedback indicated that this experience was not consistent for all patients.

This remained an area under ongoing review. The practice told us this system was in operation all day and never turned off. They told us the change had been successful overall, although some patients required time to adapt to the new system and this was consistent with patient feedback. Patient feedback on access received by CQC prior to the assessment was mixed; however, overall feedback was largely positive.

A small number of patients, including at least 3 comments, reported delays in obtaining GP appointments, difficulties using the online triage system and concerns that it was not suitable for complex needs or those requiring reassurance. One patient reported minimum waiting times of 1 week for appointments and uncertainty about accessing urgent care, as guidance on the form directed patients to use NHS 111 or 999. However, most of the feedback was highly positive, with 228 out of 240 responses indicating satisfaction with care and access. Patients described the appointment system as efficient, accessible and responsive, including timely call-backs, quick responses to online requests with instances of being seen and treated promptly. For example, one patient reported that the new online system worked well and that their request for cervical screening was reviewed and actioned within 45 minutes.

An in-house survey carried out in autumn 2025 showed generally positive feedback, with most patients reporting improved access, particularly through the online triage system, although some variation remained in telephone access and awareness of available options.

Treatment and waiting rooms were available on the ground floor and the first floor. A ramp and automatic door had been fitted to the entrance. There was a wheelchair kept at the building entrance for those that required it and all the rooms were wheelchair accessible. Due to restrictions with premises and being unable to further extend the practice building, 2 portacabins were in use at the practice

Overall, this indicated that the service was meeting patient needs and providing equitable access for most patients, with only a small number of negative comments requiring action from the practice to ensure consistent access for all groups, including those with complex needs or limited ability to use digital systems, in comparison to the high volume of positive feedback.

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.

Staff understood the importance of providing an inclusive approach to care and adjusted support equity in people’s experience and outcomes. They worked with local organisations, including within the voluntary sector, to address any local health inequalities and as a result, the practice received a Purple Star accreditation for their support of their patients with learning disabilities.

Staff treated people equally and without discrimination. Leaders told us that they proactively sought ways to address any barriers to improving people’s experience. Feedback provided by people using the service, both to the provider as well as to CQC, was highly positive, although some patients expressed their frustration in being unable to see their preferred clinician at their appointments as well some barriers in using the practice building.

The practice provided primary care services to a large care home population, with approximately 112 residents across 5 wards. There was an allocated GP lead, and 2 GP sessions were allocated for regular ward rounds, which typically equated to seeing 40 patients per round. They were supported by a weekly multidisciplinary team meeting involving care home and community staff. Additional support was provided through a dedicated community nurse and clinical pharmacist within the Primary Care Network (PCN). However, the practice reported that the level of provision remained insufficient to fully meet the significant workload and complexity of care needs for this population, although their care was maintained at a high level.

The practice told us patients with mobility issues could be seen in a room downstairs, all of which were accessible; however, monitoring was required to ensure all patients had equity in experience when using the practice. For example, a patient reported limitations in the online triage system, noting there was no option to record specific access needs, such as inability to use stairs, which caused anxiety as ground floor appointments could not always be guaranteed. They also described being offered only evening appointments via the system, which were unsuitable due to difficulties with driving in the dark.

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.

The practice was also a veteran friendly accredited practice committed to ensuring ex-forces patients had access to the best care and treatment.

The building was extended in 2004 adding 2 more consulting rooms and a waiting room upstairs. In the past few years, the practice has installed 2 portacabins in the car park to provide 2 more consulting rooms, licenced for use from 2023 to 2028.

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, feedback was not always positive in this area.

There was a palliative care lead GP and there was collaborative working with their local hospice and members of multidisciplinary team and community nurses.

The practice had patients on the Gold Standard Framework (GSF) pathway and their care was discussed at monthly GSF meetings. We saw evidence of well documented GSF meetings minutes

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. Feedback received from the care homes showed the practice was instrumental in supporting end of life care and honouring patient’s wishes in 3 instances provided by the care homes. We also saw some positive patient feedback regarding how the practice provided end of life care for their loved ones.

Patient feedback around end-of-life care was generally limited; however, we received some less positive feedback. For example, a patient raised concerns that end‑of‑life medicines had been prescribed without a recent assessment. However, this was a single account, but highlighted the importance of ongoing clinical assessment and support for patients and carers.

The care home told us that the practice worked well with other healthcare professionals, and medication arrangements were handled promptly ensuring the residents remain comfortable. Additionally we were told end-of-life care had been managed sensitively and professionally.