Clifton Court Medical Practice

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 Good. At this assessment, the rating remains the same.

This service scored 86 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider 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 National GP Patient Survey showed 96%of respondentssaid they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment, above the local average of 92%and the national average of 91%.

Care plans reflected physical, mental, emotional, and social needs of patients including those related to protected characteristics under the Equality Act. These were regularly reviewed and discussions with family documented. Our review of clinical records showed patients were supported to understand their condition and were involved in planning for their care needs, and in decisions about their care.Clinicians told us they promoted shared decision-making during consultations.

The provider understood the health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity. Services were adapted to meet local deprivation need, including access to mental health and substance misuse services. We saw the practice worked in partnership with other services to meet the needs of its patient population, including various charities.

Our review of the clinical system demonstrated that referrals to other services were made promptly, and information shared by other services was managed effectively and in a timely manner to support good outcomes for people. The provider worked closely with the Primary Care Network (PCN) with a view to improving patient outcomes.

The provider had created innovative internal dual purpose care co-ordinator/social prescribing roles, creating a holistic, joined-up approach. Those supported could access unlimited, wide ranging support including having a single point of contact, signposting to other organisations, and support to manage long term conditions. The provider recognised those with complex physical and/or mental health issues can often lack social support and experience significant health inequalities. In the previous year 255 patients had been supported, which equated to 482 hours given back to clinical time. This meant patients including the most vulnerable, could access the service easier and translated into high patient satisfaction figures for how easy they found it to access the service. GPs could concentrate more on clinical issues knowing that the care co-ordinator/social prescribing staff were giving targeted support in the areas of mental health, social isolation, housing and financial issues. We saw individual case studies, including carrying out joint home visits with a GP to patients living with dementia. This facilitated referrals to occupational therapy, help accessing community services and personalised care. It allowed the care co-ordinators to offer highly personalised support and timely interventions.

The provider had been innovative in how they identified patients with complex needs, using wide criteria including physical, mental health and social need, these patients were offered their preferred clinician, longer appointment times and multiple routes of personalised support, and were discussed in monthly multi-disciplinary meetings to ensure targeted, co-ordinated support and care. These meetings were chaired by care co-ordinators who were able to share their in-depth knowledge of the patients.

In the previous year the provider had seen a 13% drop in AE attendances compared to the year before, and a similar drop in admittances to hospital, since providing proactive, tailored interventions.

The provider supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Information provided by the practice met the Accessible Information Standard. Individual communication needs were noted on the patient’s record. Staff told us they supported patients with using online services, as many faced digital barriers. Leaflets were available in the reception area and posters were displayed to provide patients with information on the practice and the different services available to them. Easy read patient information was produced to aid accessibility. Patients were also provided with information on how to access their medical records, or for others on their behalf.

The provider made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff involved people in decisions about their care and told them what had changed as a result.

There was a complaints process in place, which included a designated complaints lead and a policy. Information on how to make a complaint was available on the practice's website. Staff showed a good awareness of complaints procedures. Themes were analysed and shared with all staff, along with changes implemented and learning points identified. Named members of staff monitored complaints progress and escalated where necessary.

We reviewed several complaints and found they were actioned in line with their policy. Where appropriate, patients were provided with an apology and signposted to the Parliamentary and Health Service Ombudsman. Information on local Healthwatch groups was also provided. The practice held regular reviews and discussions of complaints which looked at themes, learning points, changes made and other planned actions.

The latest National GP Patient Survey data showed patients reported positive experiences of accessing their GP practice. For instance, 87 %of respondents described their overall experience of contacting this GP practice as good, above the local average of 73 %and the National average of 70 %. Eighty-two per cent of respondentsfound it easy to get through to this GP practice by phone, above the local and national averages of 57%and53% respectively. Eighty-one per centof respondentsfound it easy to contact this GP practice using their website, exceeding the local and national averages of 53%and 51%. Ninety-five per cent found the reception and administrative team helpful, above the local average of 86% and the National average of 83%. When booking, 83% of patients were offered a choice of time or day when they last tried to make a general practice appointment, above the local average of 59% and the National average of 54%.

In the same survey, 17% of respondents were offered a choice of location when they last tried to make a general practice appointment, above the local average of 15% and the national average of 14%.

Out of 6,828 family and friends test responses received by the practice in 2025, 95% described their experience as good or very good. The practice monitored this data and used it to inform quality improvement activity. Through evaluation of this data, the practice was able to demonstrate clear improvement over the previous 2 years in patient experience and appointment availability.

A mixture of urgent same day, 1-2 day wait or routine appointments were available, either through telephoning, booking links or online. The provider also navigated patients externally as appropriate, such as to pharmacists or first contact physiotherapists. Home visit requests were triaged by the duty GP.

The practice received monthly management reports from their telephony system which were kept under review, allowing them to match staff to peaks in demand. Patients were offered a callback service to save waiting. Telephony reports showed the average wait time on the phone was short, and those patients wishing to receive a call back got one.

We checked the appointment system on the days around the inspection and in the afternoon, there were still 19 appointments available for the remainder of the day, with 8 unused from the morning, showing the provider was meeting demand well. The provider was innovative in how they improved access; for instance having different summer and winter rota systems for staff and appointment types, to recognise different peaks in demand, and the type of issues patients present with at different times of the year.

Patients could also attend extended access appointments at the practice until 7.30pm on Mondays, and from 7.30am on Tuesdays. Further evening and weekend appointments were available at other practices through the local GP Federation extended access arrangements.

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.Leaders and staff worked to prevent discrimination and inequality that could disadvantage distinct groups of people using their services. They proactively sought out ways to address barriers to improve people’s experience and acted on information about people's experiences and outcomes. Through work such as frailty projects, complex patient projects and opiate reduction, we saw numerous examples of patients lives improving, for instance stopping opiate use and gaining employment, and in turn helping out at support events and becoming patient advocates.

The provider was part of a pilot using artificial intelligence (AI) technology to predict a patients likelihood of missing an appointment, and proactive targeted support could then be given to understand the reasons behind non-attendance, for instance a lack of transport. We saw case studies where tailored adjustments had been made, such as support for wound dressing at home, and easier to read text messages with appointment reminders. Overall, there was an 11% drop in missed appointments following targeted intervention and support from a care co-ordinator. All patients identified as having 9 or more failed attendances received care co-ordinator support and all had substantial reductions in overall non‑attendance rates, a total drop of 47% among this patient group.

The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and Travellers. Patients could fill registration forms in online.

Staff used appropriate systems to capture and review feedback from people using the practice, including those who did not speak English or have access to the internet.The webpage for the practice had a translate function embedded in it.

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 do not attempt cardiopulmonary resuscitation (DNACPR) orders. This information was shared with other services when necessary.Regular clinical and multi-disciplinary meetings with care partners were held.