St Mary’s 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 good. At this assessment, the rating remains the same.
 

This service scored 79 (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. Leaders and staff, we spoke with all described how continuity of care was a priority within the practice, and it was important for patients to have contact with the same GP. The practice told us people who used services were involved in planning and making shared decisions about their care and treatment, for example, patients on the end-of-life pathway.

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 involved in planning for their care needs. They were also involved in decisions about their care.

The practice received above average scores in the 2026 National GP Patient Survey for questions linked to patient centred care. For example, 95% of respondents (compared to 85% nationally and 86% locally) found the reception and administrative team helpful, and 96% (compared to 87% nationally and 88% locally) said the healthcare professional they saw or spoke to was good at listening to them during their last general practice 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.

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, building relationships with local community groups to promote the take up of regular health screening programmes.
 

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. The practice had access to interpreter services, including British Sign Language if required. Information provided by the service met the Accessible Information Standard. Patients were informed as to how to access their care records.

Processes were in place to ensure people received information that was tailored to their individual needs, which included, making reasonable adjustments for disabled people and people who had difficulty with reading, writing or using digital services were supported with accessible information.
 

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

We saw complaints were managed in line with the practice’s policy. Learning from complaints was evident and staff we spoke with were able to identify changes made as a result of patient feedback, including complaints. Leaders we spoke with discussed positive changes being implemented as a result of patient feedback.
 

The service made sure that people could access the care, support and treatment they needed when they needed it.

The service offered extended appointments for people with a learning disability. People could access the service to suit their needs for example online, in person and by telephone. Treatment rooms were available on the ground floor and level access to the entrance. The practice had a range of chairs used in waiting area, including those with armrests and raised legs for mobility.

The service made sure that people could access the care, support and treatment they needed when they needed it. For example, using digital tools, supporting language needs, arranging home visits and ensuring disability needs were met. Physical premises and equipment were accessible, and people were given support to overcome barriers to ensure equal access. Clinicians were available to see people for all types of appointment requests including urgent appointments.

The service received well above average scores in the 2026 National GP Patient Survey for questions linked to access. The percentage of respondents who were positive about their experience of contacting the practice was 90% (compared to 73% nationally and 74% locally) and 76% of respondents (compared to 69% nationally and 70% locally) felt they waited about the right amount of time for their last appointment. The percentage of respondents who responded positively to how easy it was to contact their GP practice on the phone was 89% (compared to 57% nationally and 61% locally). The survey found that 78% of patients found it easy to contact the practice using the NHS App (compared to 54% nationally and 57% locally).
 

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.

Feedback provided to CQC by people using the service was wholly positive. Staff treated people equally and without discrimination. 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.

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. 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.
 

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) decisions. This information was reviewed and discussed with family where appropriate and shared with other services when necessary. There were regular multi-disciplinary meetings to discuss supporting people receiving end of life care.