Friary 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

This is the first inspection for this service since its registration and change to a new provider with CQC. This key question has been rated as good. We assessed all quality statements in the responsive key question.

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination.

This service scored 68 (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. Care plans reflected physical, mental, emotional and social needs of people including those related to protected characteristics under the Equality Act. For example, people’s care records indicated if they had a hearing impairment or required British Sign Language this helped staff who were reviewing the appointment request as they may require extra support or a longer appointment.

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.

Care provision in the service was delivered by a multidisciplinary team comprising of practice nurses, advance nurse practitioners, paramedics, health care assistants and general practitioners. Care was centred around patient needs, with a focus on timely reviews and assessments.

Staff told us patients could pre-book appointments and they also reserved on the day appointments if urgent care was needed.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. Leaflets were available in the waiting areas and posters were displayed to provide patients with information on the practice and the different services available to them.

Information to promote the take up of screening and immunisation programmes was available in a range of languages. The practice had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard. Patients were informed as to how to access their care records.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. The practice monitored NHS Friends and Family feedback, and results were mixed about the service. However, the practice could not evidence any changes that had been made following the responses.

Information was displayed on the practice’s website and within the premises to support people to share feedback and raise any concerns or complaints.

Learning from complaints was not always evident and staff were not always able to identify changes made following patient feedback, including complaints. We were told by leaders that the Central Office team collated data about complaints. Any complaints that were able to be responded to by the practice were sent to the practice manager. Complaints that were dealt with by the Central Office team were investigated and the outcome sent to the practice manager. However, records of complaints were limited, they did not provide assurance that there was a clear audit trail of communication between the Central office team and the practice. The newly recruited practice manager had implemented a new process to track complaints and outcomes. However, this new process required time to be embedded.

The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

Patient feedback from the National GP Patient Survey highlighted the following: 21% of people found it easy to get through to this GP practice by telephone, in comparison to the national average of 50%.

The practice opening hours were 7.30 am to 6 pm Monday to Friday. Same day urgent appointments were available, and routine appointments could be booked in advance. Patients could access the services in various ways that suited their needs, for example, online, in person and by telephone.

Treatment rooms were available on the ground floor with a ramp and automatic door. For accessing treatment rooms on the first floor there was a lift to ensure accessibility.

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 treated people equally and without discrimination. 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.

Feedback provided to CQC in relation to access was mixed with 41% of people telling us they had a bad experience or they had difficulties accessing appointments.

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 held a register of patients who were carers and offered annual health checks.

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. The records we reviewed 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.