Haden Vale 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.

We found people could access services when they needed to, without physical or digital barriers, including out of normal hours and in an emergency. Leaders understood the challenges to patient access and services were being designed to make them accessible and timely for people who were most likely to have difficulty accessing care, this included an increase in the number of clinical staff available. Following the closure of a local GP practice, an extra 1,000 patients had joined the practice. The provider prioritised; allocated resources and opportunities as needed to tackle inequalities and achieve equity of access.

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 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 practice told us that they regularly involved patients in planning and making shared decisions about their care and treatment that meets their needs. 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 patients including those related to protected characteristics under the Equality Act. Peoples overall experience of the GP service was generally positive as demonstrated in the National GP Patient survey, where the practice had achieved 76%, which was in line with the local average of 71% and the national average of 75%.

Patient satisfaction scores in the GP National Patient Survey were in line with local and national averages, particularly in areas relating to patient-centred care. For example, 83% of respondents found the reception and administrative team helpful, in comparison to the local average of 79% and the national average of 83%.

A review of clinical records confirmed that patients were supported in understanding their conditions and were actively involved in planning and making decisions about their care.

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.

The practice understood the needs of its local population and were taking action to develop services in response to those needs. Through the PCN, the practice staff were able to offer patients access to other services such as social prescribing, physiotherapy and mental health nurse to support their overall health and wellbeing. We saw the practice worked in partnership with other services to meet the needs of its patient population.

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

The practice website included useful information on health awareness and promotion. Information and resources were available for patients to support them to understand how to access services. For example, the practice had access to interpreter services, including British Sign Language and people who may be digitally excluded.

There were systems in place to support patients to access treatment and patient records were held in line with guidance and requirements. We found the practice complied with the Accessible Information Standard (AIS) and that information about people collected and shared was in line with data protection legislation requirements. Patients were informed 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. 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. Information about how to complain was readily available and patients could make a complaint in person or via the practice website.

Feedback from the GP national patient survey demonstrated that 86% of patients say the healthcare professional they saw or spoke to was good at listening to them during their last general practice appointment. This was in line with the local average of 84% and the national average of 87%.

The leadership team told us they were trying to implement a patient participation group (PPG) and had sent a link out to people asking them if they were interested in joining. We were told that the practice had received a number of positive responses. Whilst the PPG was in planning stage, a range of coffee mornings had been implemented to provide updates to patients. We found these were being held on a monthly basis and the practice had invited guest speakers to some of the events to provide advice and support.

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

The practice was responding to the needs of their population and were developing services in response to those needs, this included the appointment of an advanced nurse practitioner to start in August 2025 to provide support to the clinical team and increase appointment availability. The practice told us they obtained feedback from various sources such as complaints and via informal feedback from patients. The GP national patient survey showed 53% of respondents found it easy to get through to the provider by phone. This was in line with the local average of 48% and the national average of 53%. Feedback received by the CQC highlighted difficulties in obtaining appointments. People told us they struggled to get through to the practice by phone and were unable to book appointments when needed. Staff feedback also highlighted concerns with access and appointment availability,

Patients could access appointments by phone and by visiting the practice and submit non-urgent medical and administration requests online via the practice website. A callback service was also available for people who found they were unable to wait to get through to the practice. On the day of the onsite assessment, we noted staff doing call backs to people who had requested this. The practice used a sign-posting triage system where reception staff would ask the patient for enough information to make a decision regarding which clinician was appropriate for them to see. Patients were given the option of a face to face or telephone appointment. Patients who had a request for an emergency appointment were seen the same day. The practice website provided information for patients regarding how to book an appointment. Feedback from staff demonstrated people in vulnerable circumstances were able to register with the practice, including those with no fixed abode.

Appointments with a GP were available throughout the week. When the practice was closed patients were able to contact 111. The practice offered appointments from a variety of additional clinical staff for example nurses and a pharmacist. Pre-booked appointments were available on weekday evenings and at the weekend through an arrangement with other local GP practices.

The practice had arrangements in place for prioritising patients. Staff were trained to book appointments with members of the practice clinical team or signpost patients to other appropriate services and were supported by a duty doctor. Treatment rooms were available on the ground floor and a ramp and automatic door had been fitted to the entrance.

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.

The practice had promoted and responded to feedback by people who used the service within the last 12 months. People could leave feedback via NHS UK, the practice website and via the Friends and Family test (FFT). Information provided by the provider showed in February 2025 they had received 132 responses from FFT which showed 61% rated the practice as very good and 22% as good.

The provider complied with legal equality and human rights requirements, including avoiding discrimination, having regard to the needs of people with different protected characteristics and making reasonable adjustments to support equity in experience and outcomes, including meeting the Accessible Information Standard (AIS). We saw examples where the practice had removed barriers for improved patient experience. For example, the practice had access to interpreters. People with learning disabilities and poor mental health experienced additional care through annual reviews and the support of a care co-ordinator. People with dementia were referred to appropriate services where required.

Feedback provided by people using the service, to the provider was positive, however feedback received by the CQC was mixed with negative comments on the services provided. 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. 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.

Leaders understood the requirements of legislation when considering consent and decision making and had access to policies to support them. We were told that the practice held multidisciplinary meetings to share and discuss information relating to patient care and treatment, for example, those on the practice palliative care register.

There were registers held for those patients who were vulnerable who were on the palliative care register or at the end of their life. We found that clinicians understood the requirements of legislation and guidance when considering consent and decision making and saw that consent was documented.

Our records review 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.