Custom House 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 requires improvement because they had not improved their GP Patient Survey results relating to access.

At this assessment, the rating had changed to good in part due to improvements in access, with the service performing in line with local practices for the proportion of patients who responded positively to their overall experience of contacting the service.

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 had ensured people were at the centre of their care and treatment choices and had worked in partnership with them to respond to relevant changes in their needs.

The provider understood the diverse health and care needs of people and their local communities, so care had been joined-up, flexible, and had supported choice and continuity.

We saw the provider worked in partnership with other services to meet the needs of its patient population. Services were tailored to meet the diverse needs of the community, for exampleby working collaboratively with external stakeholders, such as ICB, PCN, social prescribers, local libraries, and multidisciplinary teams to provide coordinated care, deliver health education, improve digital inclusion, and ensure patients could access a wide range of in-house and community-based services.

The latest national GP Patient Survey had found that 91% of respondents felt the healthcare professional they saw had all the information they needed about them during their last appointment. Patients we spoke with during the assessment confirmed that the healthcare professionals they had seen had the necessary information to support their care.Leaders and staff explained how they had ensured information was available to as wide an audience as possible. Staff told us they had understood people’s communication needs. People using the service, their families, and carers were provided with information that was accessible, safe, secure, and supportive of their rights and choices.The service made reasonable adjustments for disabled people, interpreting and translation services for people who did not speak English as a first language, and support for deaf people who used British Sign Language.

The latest national GP Patient Survey found that 79% of respondent patients had stated the healthcare professional they last encountered was good at listening to them during their last appointment. In addition, 89% said they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment.

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

People could access care, treatment and support when they needed to and in a way that worked for them which was reinforced by an access to appointment protocol. This promoted equality, removed barriers or delays and protected their rights. Patients told us they could access clinical care when desired via different avenues. However, one patient told us that on occasion appointments ran 30-45 minutes late.

Following the service’s review of their GP Patient Survey results the service implemented a range of initiatives to improve patient access, efficiency, and engagement. It strengthened operational management by appointing an Operations Manager who oversaw daily processes, streamlined appointment systems, allocated resources effectively, reduced bottlenecks, coordinated teams, and monitored performance to support timely access to care.

Through participation in a structured improvement programme, the service enhanced leadership, teamwork, and accountability while reviewing workflows and using patient feedback and data to improve access and ensure patients were directed to the appropriate clinician promptly.

Digital access was improved through the introduction of an IT lead, who supported staff training and patient engagement initiatives, including workshops to promote use of digital tools for managing appointments and accessing records.

The service adopted proactive approaches to appointment management, including multi-channel reminders, online booking and self-management options, structured slot allocation, and targeted follow-up for missed appointments. It also educated patients on the importance of attendance and appropriate service use, while continuously monitoring data to adapt capacity and reduce delays.

On-site services were expanded to provide integrated, accessible care, including welfare support, contraceptive services, blood testing, and general nursing care, enabling timely intervention and reducing the need for external referrals.

In addition, the service promoted well-being through regular community initiatives such as coffee mornings, which fostered social connection, reduced isolation, and contributed to a supportive and inclusive environment for both patients and staff.

Systems had been in place to recall and invite patients for childhood immunisations and cervical cancer screening.

Treatment rooms had been available on the ground floor, and an automatic door had been fitted to the entrance.

Staff and leaders had actively listened to information about people most likely to experience inequality in experience or outcomes and had tailored care, support, and treatment accordingly. Leaders had proactively sought ways to address barriers to improving people’s experience and had worked with local organisations, including those in the voluntary sector, to address local health inequalities.

Following the service’s assessment of population need, a monthly coffee morning was introduced at the practice. This initiative aimed to address wider barriers to health and wellbeing, recognising that many patients experienced challenges such as housing instability, financial pressures, and difficulties navigating support services.

As part of this approach, external organisations were invited to provide targeted support and information. For example, Prostate Cancer UK delivered a session for male patients, raising awareness of symptoms, early warning signs, and available screening options.

In addition, the Department for Work and Pensions (DWP) attended the practice twice weekly, offering one-to-one appointments to support patients with benefit enquiries and access to financial assistance.

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.

People had been given the opportunity to express their wishes regarding DNACPR and were supported to plan their future care while they still had the capacity to do so. People’s decisions and what mattered to them had been reflected in personalised care plans, which had been shared with others when necessary. The patients we spoke to during the on-site assessment told us they had felt involved in decisions about their care and treatment.