The Bacon Lane 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 inspection in July 2023, we rated this key question as Requires improvement. At this assessment, the rating has changed, and we rated this key question as Good.

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 practice 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. 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 national GP patient survey data (2024) showed that 91% of the respondents felt they were involved as much as they wanted to be in decisions about their care and treatment.

The practice understood the diverse health and care needs of people and their local communities, and ensured service delivery was coordinated, flexible and supported choice and continuity.

The practice had tailored its services to meet the diverse needs of its community. For example, it was 1 of only 2 practices in the local area to offer skin lesion excision. The practice also offered joint injections, further enhancing the range of services available to patients.

We saw the practice worked in partnership with other services to meet the needs of its patient population and established mechanisms for engaging with the community healthcare providers. For example, the practice utilised the computer software platform to create dedicated communication channels with the district nursing team and local pharmacies, promoting real-time collaboration and continuity of care. The practice implemented the NHS Pharmacy First model, improving patient access and reducing pressure on GPs by directly triaging suitable conditions to community pharmacies.

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

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. For example, the social prescriber we spoke with described how they had supported patients in downloading the NHS app and accessing their care records online.

The practice 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. Over the past 12 months, the practice received 46 complaints. There was clear evidence of learning from complaints, and staff were able to describe improvements made in response to patient feedback. For example, the appointment booking system was reviewed and improved, allowing patients to now submit booking requests via email.

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

Staff received the right training to ensure equity in access for the patient population.

There were accessible facilities, which included a disabled toilet, and a hearing induction loop was available.

The practice offered longer 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.

The practice informed us that the telephone system included a queueing facility and remote monitoring via a dashboard. The practice demonstrated how they effectively analysed this data to improve service delivery and were discussing telephone performance data regularly at team meetings. We noted most calls were answered within 30 seconds.

According to the National GP Patient Survey, 58% of respondents found it easy to access the practice by phone, which was above the national average of 50%.

The Patient Participation Group (PPG) members we spoke with during the assessment were satisfied with the access provided by the practice. They were happy with the new telephone system and reported being able to book appointments when needed.

The practice had 9,990 registered patients. On the day of the assessment, we found the practice offered 41 GP clinical sessions per week (including 10 trainee GP clinical sessions). In addition, 2 clinical pharmacists were employed by the practice and offered a combined total of 67.5 hours per week at the practice. The practice offered 19 practice nurse clinical hours per week. The practice also employed a Musculoskeletal (MSK) specialist for 16 hours per week and had 2 full time Health Care Assistants (HCAs) working at the practice.

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 by people using the service, both to the provider 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 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.

Staff were trained on equality and diversity.

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 cardiopulmonary resuscitation. This information was shared with other services when necessary.

The DNACPR records were reviewed and updated according to the Mental Capacity Act. Care plans were updated according to the changing needs of the patients. The wishes of the patients were respected.