The Village Green 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

People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.At our last assessment, we rated this key question as good. At this assessment, the rating has changed to outstanding.

This service scored 89 (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 was exceptional at making 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.

Feedback from people collected by CQC indicated that patients felt listened to, and that the practice recognised individual needs. According to the NHS England GP Patient Survey 2025, 77% of patients would describe their overall experience of Village Green Surgery as good, this is higher than local (73%) and national averages (70%). The NHS England GP Patient survey showed that 90% of patients who completed the survey felt their experience was good, which is above averages, both locally (79%) and nationally (75%).

We spoke with the patient population group who told us, the practice is exceptional at recognising the needs of patients, they understand the complexities of patient circumstances and can recognise if someone needs further support. An example provided was the coding of patients who may be deaf and therefore find it difficult to order medications over the phone, allowing either a family member to order on their behalf. The patient participation group told us that this issue was raised and resolved quickly and effectively. All staff who completed our questionnaire told us that the practice puts patients at the centre of the practice. 93% of patients who completed the patient survey indicated that reception and admin staff were helpful and friendly and 93% also stated they felt listened to during the appointment, this is once again above local and national averages.

The service had an exceptional 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.

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, carrying out an audit which looked at risk factors of the patient list, lung cancer was identified, a screening tool was created, the results we reviewed had positive outcomes for patients. Close and positive relationships were held with community services, aligned care homes, the practice recognised that care home residents are within a vulnerable group of patients, and implemented one GP to take responsibility to ensure their care was continuous. This was not only of benefit to patients but also relatives and staff within the homes. The practice acknowledged the importance of working with other services and provided examples of demonstrating learning from within the practice nationally at conferences, this involved care navigation, and a quality improvement project focused on lipids (high cholesterol). This project was led by the practice pharmacist, and we reviewed evidence which demonstrated a project which improved outcomes for almost 1000 patients. The project is currently in its third cycle and had been rolled out to more patients within the PCN. Leaders of the aligned care homes told us that they had no problems in accessing care for their residents, and there was good continuity of care provided by the practice. Care homes had a named GP to ensure consistency. The practice had supported care home leaders in collecting data regarding access, to monitor the implementation of the online access system with this specific population.

The patient participation group (PPG) told us they had a positive experience with how the practice worked with them to improve the quality of care and service for patients. We were told that the PPG had been involved in the development and roll-out of the online access system as well as consulted in overcoming challenges with the phone system.

The service was good at developing appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The practice had information on their website to support national priorities and initiatives to improve the populations health. For example stop smoking campaigns, diabetes prevention, and vaccinations. Various resources such as communication aids, interpretation services, and confidentiality request cards were available to patients. There was a variety of information available within the waiting room, and information provided by the service met the Accessible Information Standard. Patients were informed as to how to access their care records and make a complaint if needed.

Translation services were available both in person and via telephone. Leaders were able to provide examples of reasonable adjustments that had been implemented on an individual scale. Admin staff had a knowledge of patients who may require support around communication and were able to ensure this was provided at the point of requesting an appointment.

Senior leaders reviewed all subject access requests on a quarterly basis to ensure these had been responded to and actioned within the appropriate time frame.

We saw resources that had been created by the practice that communicated the changes being made in various formats. The practice had an active social media page which provided information on the local area and provided updates such as instances where patients may not be able to access the surgery, due to unforeseen circumstances.

The service was exceptional at enabling people to share feedback and ideas, or raise complaints about their care, treatment and support. They always involved people in decisions about their care and told them what had changed as a result.

A representative from the Patient Participation Group (PPG) told us that they felt included in discussions, and that their feedback was listened to by practice leadership. They told us that there had been changes made quickly where they could be.

According to the NHS England GP Patient Survey 2025, 93% of patients who responded felt that they were listened to by the healthcare professional at their last appointment, compared with a national average of 87% and a local average of 83%.

Leaders told us that feedback was regularly collected from patients via the Friends and Family Test. This data was reviewed by the practice team and displayed on the website and in the practice waiting room. Staff told us that they were able to share feedback and ideas with leaders and felt this was taken into consideration and acted upon. This could be done in person, via telephone or online.

We saw evidence of a robust complaints process. Complaints were reviewed and responded to in line with practice policy, and themes and trends were reviewed by senior leaders at an annual meeting. Complaints and significant events were discussed within documented meetings, with learning points distributed to staff. Leaders also ensured staff understood learning and put it into daily practice. We saw evidence of protocols being updated following complaints, for example a delay in warfarin when blood results had not been updated correctly. A new protocol was implemented and staff given training to ensure this did not happen again.

We reviewed evidence which indicated constituent positive outcomes for patients, these outcomes were shared across the local area, involving patients across North Tyneside and Northumberland, for example a significant event which highlighted an IT error, the findings were shared ensuring the risk of patient results being lost was minimised across Northumberland and North Tyneside and not just within the practice.

We saw examples of changes that had been made to processes and audits that had been introduced as a result of patient feedback, complaints, or significant events. Practice leaders told us that individual needs of people were always considered, and people were involved in decisions about their own health. For example, patients who requested for a gender to be documented differently, or pronouns be altered would be offered discussion with a clinician and a personal care plan commenced to ensure they were involved in decisions about care. Furthermore, when the surgery made significant changes in practice, patients were sent surveys which were clearly reviewed and actioned where needed.

All new patients who registered with the practice were offered an appointment to discuss healthcare needs they may have.

Staff and leaders were innovative in how they listened to information about people who were most likely to experience inequality in experience or outcomes. Staff and leaders actively used this information to provide exceptionally tailored care, support and treatment in response to this.

Feedback from people collected by the provider and CQC was positive. Leaders proactively sought ways to address any barriers to improving people’s experience. The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as people with no fixed address.

Leaders told us that people could contact the practice in various ways, to meet individual needs, these needs were clearly documented in patient records. Resources were made available to patients, such as communication cards, that allowed people to make their needs known to the practice in an attempt to eliminate barriers to accessing care. Practice leaders had reviewed their online access system and identified a significant increase in patients using online systems since last year. This was further broken down where possible into demographics allowing for leaders to identify groups who were not using online services, such as the elderly.

Leaders told us how they engaged with hard to reach groups, providing home visits to those who had not responded to correspondence from the practice. These visits provided healthcare by an advanced practitioner, as well as social and mental health support by the wellbeing lead. Practice leaders were aware of challenges being faced by primary care services and were working to improve. For example, recognising the challenges with opioid prescribing and conducting an audit and review of all people prescribed certain medications, which included consultations with the patients themselves.

Staff and leaders were innovative in how they listened to information about people who are most likely to experience inequality in experience or outcomes. Leaders had an excellent knowledge of the patient population and were able to highlight certain groups who were at higher risk of missing appointments or needing extra support in accessing healthcare. The practice had a lead GP for their patients who resided in a care home which ensured this patient group were known to a clinician and reviewed regularly. This benefited patients who may have fluctuating capacity or who struggled with decision making as the GP would be aware of the baseline of these patients.

Staff and leaders actively used this information to provide exceptionally tailored care, support and treatment in response to this, for example patients who fell into the pre diabetic category, staff were able to opportunistically monitor these patients outside of there usual reviews, to provide health promotion. The results of the most recent audit of these patients demonstrated a decrease of 53% of those screened as being pre-diabetic. The National GP Patient survey demonstrated that 100% of patients with a long term condition knew what would happen following an appointment at the surgery, compared with 93% national and 94% locally.

Feedback provided by people using the service, both to the provider as well as to CQC, was positive. We reviewed feedback which outlined patients felt they were kept informed accurately. Staff contacted them when they said they would do so. Patients also told us staff took the time to ensure they understood what was being disclosed.

Staff treated people equally and without discrimination. Staff had recently appointed a domestic abuse lead who worked within the administration team, the aim of this staff member was to ensure victims who may not attend appointments, or who required flexibility in how they accessed the service could be overseen.

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. The practice worked with local foodbanks and schools to provide support where they could.

Staff understood the importance of providing an inclusive approach to care and adjusted support equity in people’s experience and outcomes. Staff had carried out work around online access to the surgery, and looked at which groups of patients were not using NHS App. Patients were asked by staff at Reception and Nurse Reception if they needed any assistance in setting this up. The National GP Patient survey indicated that 80% of patients found the online services easy to use, in contrast with a 51% national average and a 53% local average.

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. Those with no fixed abode could register the practice as their address in order that they could access secondary care.

When the practice implemented the Continuity of Care project, which aimed to align patients to one regular GP, they commenced with the most vulnerable patients first in order that those who needed access to a regular GP were able to be prioritised. The National GP Patient Survey which took place prior to the project commencing demonstrated that 61% of patients were able to access their preferred clinician against a national result of 40% and local 41%. Patients with a learning disability, or any other protected characteristics were aligned with a clinician who had most input with their care, to continue this positive trend.

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. These conversations included family members, and support was offered to family members who had potentially stepped up into a carers role. There was a regular palliative care meeting which was attended by healthcare professionals. Palliative care registers were kept up to date.

Aligned care home staff provided positive feedback in this area, describing the work done by the practice as person-centred and caring. We were told that Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) documentation and emergency healthcare plans were reviewed regularly by the practice and kept up to date. The practice had a named care home GP which demonstrated continuous care.

Furthermore the practice carried out an audit to look at improving discussions regarding palliative care patients in meetings. In particular how to raise sensitive issues like DNACPR and EHCP’s. This audit involved comprehensive review of the palliative care list at the practice. This audit which is ongoing has resulted in actions regarding the improvement of coding patients accurately and sensitively in these situations, better discussions in team meetings and ultimately better care for patients.