Jorvik Gillygate 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 outstanding. At this assessment, the rating is good.

This service scored 82 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Jorvik Gillygate Practice was exceptional at ensuring 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.

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.

A specific example of the work the practice had undertaken to provide person-centred care was the development of its care coordinator service.

The practice identified that housebound patients with multiple long‑term conditions were experiencing fragmented and reactive care, with inconsistent monitoring and limited structured reviews. In response, the practice repurposed the PCN care coordinator role to provide more proactive, person‑centred support. Care coordinators now deliver planned reviews across priority groups, including housebound patients, people with dementia and those with serious mental illness. Through scheduled home visits, they gather comprehensive clinical information, review medication access and adherence, support carers, and coordinate referrals to health, social care and community services, with findings fed back to GPs for clinical oversight and follow‑up.

This model has had a significant positive impact on care quality and continuity. It has improved the consistency and coverage of long‑term condition and mental health reviews, strengthened clinical documentation and coding, and enabled earlier identification of unmet needs such as safeguarding or social support issues. Overall, the introduction of care coordinators has shifted care from a reactive to a proactive approach, resulting in better coordinated, more personalised care and improved safety and outcomes for some of the practice’s most vulnerable patients.

Jorvik Gillygate Practice 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.

We also saw that the practice had tailored its services to meet the diverse needs of its community. For example, over the last 12 months Jorvik Gillygate Practice had supported a GP led collaborative within York, to deliver proactive case management for the frailest patients across the city.

As part of this project, the practice had hosted a weekly Complex Frailty Multi-disciplinary team meeting which brought together a range of allied health professionals (including frailty nurses, community physiotherapists, dieticians, social prescribers, and social workers) and helped deliver annual Comprehensive Geriatric Assessments within the community.

This project had resulted in the earlier identification of unmet needs (particularly mobility decline, nutrition risk, falls risk, cognitive concerns, and carer strain) and had also led to a reduction in acute cases requiring emergency admission. In addition, there had also been improvements in patient and carer experience through proactive, personalised care, plus increased clinician confidence in managing highly complex patients in the community.

Jorvik Gillygate Practice supplied appropriate, accurate and up-to-date information in formats that were tailored to individual patient needs.

The practice website was available in multiple languages, with compatibility for screen readers and adjustable text size.

Staff had access to interpreter services and communication support (like British Sign Language interpreters, a text relay service, and speech-to-text tools) was also available. The practice could also provide information in large print or ‘easy read’ formats, supported by visual aids where appropriate. Some staff had been trained in British Sign Language to support patients.

Arrangements were in place to ensure compliance with NHS England’s Accessible Information Standard. Patients were informed via the surgery’s website and via a patient information pack as to how to access their medical records.

Results from the National GP Patient Survey showed that 83% of patients stated that they knew what the next step would be after contacting the practice, which was in line with the national average.

95% of patients also said that they knew what the next step would be within 2 days of contacting the practice as compared to the national average of 93%.

The practice planned to transition to a total triage system for appointment booking in June 2026, with the aim of improving the use of resources and supporting patients to access the most appropriate care within appropriate timeframes. Early engagement took place with the Patient Participation Group (PPG) in January, which informed the development of clear and accessible patient information and communication materials. These materials were co‑produced with the PPG and a multi‑channel communication plan was in place, including updated posters, leaflets, website and social media content, to ensure patients were well informed. Staff have been fully engaged through whole‑team meetings, with learning shared from another local practice and opportunities for feedback to support safe implementation. Additional support will be provided during the initial rollout through increased staff presence and trained care navigators in waiting areas.

Jorvik Gillygate Practice 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.

People could provide feedback or raise concerns in a variety of ways, including online (via their website), by email, letter or verbally. Patients were also encouraged to share feedback through the NHS Friends and Family Test. During our assessment, we saw feedback boxes and forms available in the waiting areas at Woolpack House, with posters promoting the NHS app and the CQC’s ‘Give Feedback on Care’ Form.

Complaints were managed in line with the practice’s complaints policy, and learning from complaints was evident. Staff were able to describe changes that had been made in response to patient feedback, including complaints, demonstrating that feedback was reviewed and acted upon to improve the service.

The practice had an active Patient Participation Group (PPG) and held regular, quarterly meetings with them. A member of the PPG confirmed that practice staff had attended meetings to discuss issues with access, online booking, follow-up appointments, and staff consistency, and that comments and suggestions from the PPG were taken seriously. They also told us that the practice was receptive to feedback and genuinely welcomed the PPG’s involvement.

We saw a dedicated PPG noticeboard in the reception areas at each practice. This included the minutes of the most recent PPG meeting, along with information about the role of the PPG and how patients could get involved.

The PPG had undertaken a significant amount of work in partnership with the practice and external organisations to promote patient engagement, improve health awareness and support vulnerable groups within the community. This included holding a dementia awareness open day, fundraising for a local dementia charity, consulting on improvements to the practice website to enhance usability, and running NHS App training events to increase patients’ confidence in using digital health tools.

The PPG also worked with the practice’s Carers’ Champion in local schools to identify young carers and improve their access to support. This work had resulted in a 300% increase in the identification of under-18 carers registered with the practice.

Further improvements made following feedback from the PPG included changes made to the recorded telephone message, amendments to coding which led to a 31% increase in recorded veterans, improved signage for toilet facilities, and the introduction of rotas for care navigation staff to better match demand and reduce call waiting times.

Jorvik Gillyagte Practice ensured that people could access the care, support, and treatment they needed, when they needed it.

The practice operated across three sites, providing flexibility and choice to support equitable access. Woolpack House, the main site, was open from 8am to 8pm on Mondays; 8am to 6:30pm Tuesday to Friday; and 8:45am to 1pm on Saturdays. South Bank Medical Centre and East Parade Medical Practice were open from 8am to 6:30pm Monday to Friday. Patients were offered appointments across all sites, dependent on clinical need, clinician availability, and the service required. This approach supported timely access and increased choice, particularly for patients who may benefit from appointments at alternative locations.

Arrangements for enhanced access were in place outside of core hours and were delivered collaboratively on an equitable basis with another practice within the York City Primary Care Network (PCN). Evening appointments were available each weekday from 6:30pm to 8pm, with additional appointments offered on Saturdays from 9am to 5pm across the two practices. These arrangements increased access for people who may find it difficult to attend during standard opening hours.

Feedback from the National GP Patient Survey reflected generally positive experiences of access. Overall, 77.6% of respondents reported a positive experience when contacting the practice, which was above both the local average (72%) and the national average (70%). A higher proportion of patients (58%) reported that it was easy to contact the practice by telephone compared with the local and national averages of 53%. In addition, 81% of respondents felt they waited the right amount of time for their most recent appointment, which compared favourably with local and national figures (69% and 67% respectively).

Responses relating to digital access showed a mixed picture. 40% of respondents reported that it was easy to contact the practice via the practice website, which was below the local (57%) and national (51%) averages. However, 60% of respondents found it easy to contact the practice using the NHS App, which was higher than both the local (54%) and national (49%) averages. These findings demonstrated that while some digital access routes may require further development, alternative digital options were working well for many patients.

Choice of appointment location was also a strength. 35% of respondents reported being offered a choice of location when they last attempted to make an appointment, which was significantly higher than both the local (18%) and national (14%) averages. This supported equitable access for patients with preferences or needs linked to location.

We observed that physical access arrangements varied across sites. Both practices visited had clear routes to their main entrances and good external signage. At Woolpack House, access within the building was good, with treatment rooms located on the ground floor, an automatic entrance door, accessible parking spaces, and flat access to the entrance. A lift was available to support access to first- and second-floor areas.

At South Bank Medical Centre, there were no designated accessible parking spaces. The main entrance was accessed via steps; however, an accessible entrance was available to the side of the building. Patients using wheelchairs or pushchairs accessed this entrance via an intercom system. Where required, clinicians moved to a ground-floor clinical room to see patients who could not access upper floors. This ensured patients were still able to receive care despite environmental limitations.

Waiting areas at both practices were accessible and included seating at various heights. Hearing loops were available at both sites to support people who were hard of hearing. Reception areas were clearly identifiable at each practice, and a self-check-in screen was available at Woolpack House to support patient independence.

The practice worked in partnership with York Disability Rights Forum in 2024 and 2025 to further understand and improve accessibility and an audit tool was developed for auditors from the Forum auditors to use at each site. These audits focused on assessing the accessibility of each practice and their services for disabled people and people with long-term conditions, including those with sight and hearing loss. As a result of this work a number of recommendations were made, many of which have been acted on.

Home visits were offered to patients assessed as unable to attend the practice, supporting equitable access and continuity of care for people with reduced mobility, significant illness, or other barriers to attending in person.

The practice added reminders to the home screen of patients with additional support needs so that reasonable adjustments could be made. Where appropriate these patients would be offered continuity of care with a named GP or clinician or support from the care coordinator team, planned appointments booked in advance, written patient-specific engagement plans and involvement of advocates or carers.

Jorvik Gillygate Practice also operated a Care Home Service designed to provide care for frail older adults and for residents living with multimorbidity, dementia, and complex health needs in residential and nursing settings. At the time of our assessment, the practice was responsible for two local care homes and delivered a structured model of support, including weekly dedicated GP/ACP/Pharmacist ward rounds, a named clinician for each home, a medicines optimisation review programme, and rapid triage with same‑day clinical input when required. Feedback from care home staff indicated high levels of satisfaction with the service provided.

The practice recognised the importance of equitable access to screening and actively monitored transgender and non-binary patients for cervical screening eligibility, following up on patients who did not attend after receiving an invitation. This approach ensured that patients who may fall outside standard automated recall systems were still offered screening and appropriate follow-up.

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 majority of feedback provided by people using the service, both to the surgery as well as to CQC, was 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 practice had processes to ensure people could register at the practice, including those in vulnerable circumstances. They did not refuse to register patients who were unable to provide identification or a fixed address and had a policy of registering all patients unless they lived outside of their designated practice area. No patients had been refused registration in the 3 months prior to our assessment.

The practice was an Armed Forces Veteran Friendly Accredited GP practice. This meant that there was a clinical lead for veteran health who undertook regular training to better understand the needs of veterans and support veterans to access dedicated health services.

Jorvik Gillygate Practice had an embedded mental health service for patients aged 18 and over, designed to provide early intervention and timely access to mental health support. The service was PCN led and operated with no barriers to entry or re-referral for eligible patients. People using the service were offered prompt support through first-contact telephone appointments, followed by further assessment, therapeutic intervention, signposting, or referral as appropriate.

The service actively aimed to reduce health inequalities across York by supporting individuals who may experience difficulty accessing traditional mental health pathways.

Since its inception, 398 patients had completed interventions through the service, with a total of 3,980 sessions delivered. The average waiting time was 2–3 months, compared to 10–12 months for NHS Talking Therapies. By providing earlier access to support, the service contributed to improved patient experience and outcomes and helped reduce pressure on secondary care and other local services.

Jorvik Gillygate Practice supported people 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. Palliative care patients had a named GP.

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.

Five patient records were reviewed where a ReSPECT (Recommended summary plan for emergency care and treatment) form or a DNACPR (Do not attempt cardiopulmonary resuscitation) form was in place.

All patients were flagged appropriately on the patient’s clinical record following notification of the decision. Where ReSPECT forms had been completed by practice staff, a copy was held on the patient’s clinical record as per best practice.