Holmside Medical Group

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 82 (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 was exceptional at making 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.

One of the salaried GPs at the practice led the learning disability service. They had had completed a fellowship in learning disability and had published an academic audit regarding this.They were assisted by a member of staff who was the learning disability care coordinator. Year on year from 2022 to 2026 the practice had increased the number of reviews completed, over the 4 years an increase of 63%. This was achieved by a structured process of follow up for non-responders, by risk assessment and flexible options for attendance.

The practice had a high prevalence of patients suffering with mental health, 3.9% above the integrated care board (ICB) average. They implemented a pro-active redesign of their mental health provision. They embedded mental health practitioners and workers within their clinical team ensuring that patients could be seen on the same day following triage, reducing escalation, preventing deterioration and ensuring early intervention. This approach had freed up 766 extra GP appointments in a year. Patient feedback on this service included, reporting feeling heard, validated and understood. The interventions had reduced anxiety, stress and panic and gave confidence to those seeking mental health support. The practice had multi-disciplinary meetings with the community mental health team.

The practice had increased year on year the number of long-term condition (LTC) reviews and introduced their own holistic housebound LTC reviews, which looked at clinical and social issues for the patients.

As a result of linking training and development with quality and innovation the practice had expanded or strengthened services which included, providing minor surgery, Intrauterine Device (IUD) fitting and removal, contraceptive implants and pessaries for pelvis floor prolapse. These services were provided to GP practices in the locality as well as to their own practice population.

The service 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.

Staff, teams and services were committed to working collaboratively, people who had complex needs and were supported to receive coordinated care. There were innovative and efficient ways used to deliver more joined up care to people who used the services.

The practice enabled a non-commissioned community hub set up by the primary care network (PCN) they were part of. The PCN collaborated with many local providers and services. This was called ‘The Space’. It is a one stop shop café environment, operating every Friday. It was a place where patients who suffer with mental health can receive joined-up, person-centred support, moving away from isolated services and was delivered in a place where people feel safe to ask for help. This was set up in 2024 and has been visited by the Integrated Care Board (ICB) and NHS England. In 2025 a report on this service was complied and the findings presented at a healthcare scrutiny board to roll it out across the area. There were 250 attendances in a year. In this hub patients could be seen directly for example, by drug and alcohol services, homeless charities, the local authority mental health social work team, financial, housing and welfare rights services, the city’s social housing service and a counselling service. The practice provided us with case studies of patients where they received positive feedback and were able to onward refer patients to services who could support them in the long term.

The service 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.

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 were able to identify changes made as a result of patient feedback, including complaints.

Patients had asked if they could have a more personal experience on the phone with staff and asked that staff said their names at the start of a phone call which was put into place.

Data from the National GP Patient Survey told us the percentage of patients who stated that during their last appointment the healthcare professional was very good or good at listening to them was 90.3% compared to the national average of 86.9%.

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

The practice reviewed their appointment system in 2022 to 2023. The clinical team reported being stretched and reception reported they wanted to be able to offer a better appointment system. They had a meeting with the staff to discuss this and take forward ideas. The strengths and weaknesses of all types of appointment systems was discussed.

A triage of on the day requests was implemented and this moved to 15-minute appointments. These could be by telephone, face to face or video. This was tested and feedback gathered from patients via NHS friends and family, internet reviews, a patient survey and the practice patient participation group (PPG).

The practice found that the percentage of face-to-face appointments was above the integrated care board (ICB) average, this was exceeded by 6% to 12% every month. The do not attend (DNA) rate was below 5%, and actions to ensure this included DNA texts going out in the correct language.

The system was continually reviewed. In November 2025 the practice moved to a GP only triage of all appointments. An early audit of this showed appropriate clinical decision making, effective use of signposting, improved continuity of care and good communication between administrative staff and clinicians.

Further improvements included templates to improve triage, and the online consult application. The staff workflows were more effective, for example fit notes (fitness for work) via eConsult. The staff felt that patients were now receiving the right service at the right time and staff feedback had led to action. The dedicated visiting GP each day had led to improved response times for palliative and end of life care patients.

The practice were part of the National General Practice Improvement Programme (GPIP) which is an NHS England initiative designed to help practices modernise, manage increasing demand, and improve patient access.

The practice is classed as a 'deep end practice' due to the high levels of deprivation. Last year they completed a healthier lives project in collaboration with the Deep End Network and Newcastle University. The aim of the project is early identification and prevention of health issues, targeting patients who would otherwise remain unseen and to tackle health inequalities.

In addition to the triage system the practice had access to allied healthcare professionals such as mental health practitioners, physiotherapy and a home visiting GP.

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.

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.