The Armada Family 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 has not changed
 

This service scored 71 (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.
Care plans reflected physical, mental, emotional, and social needs of people, including those related to protected characteristics under the Equality Act 2010. For example, people’s care records indicated if they had a visual impairment. This alerted staff reviewing their appointment request that they may require additional support to attend.
Where people were receiving support from a health coach, they had individualised goals such as healthier eating and worked in partnership to achieve these.
We saw evidence of the service offering reasonable adjustments and took individual preferences into consideration. For example, offering access to interpreter services and information was available in a variety of formats such as large print or easy read. This helped people understand their care, treatment, and health conditions.
 

The service understood the diverse health and care needs of people and their local communities, to promote joined-up care and continuity.
The service worked with other service providers to meet people’s needs, this included colleagues from the district nursing team. The service also supported people to access mental health practitioners through a shared agreement with the local mental health team.
 

The service supplied appropriate, accurate and up-to-date information in formats tailored to individual needs. Translation services could be accessed to support people who did not have English as a first language.
Information to promote the take up of screening and immunisation programmes was available in a range of languages. The service had access to interpreter services, including British Sign Language.
Information provided by the service met the Accessible Information Standard. People were informed as to how to access their care records.
The service’s website contained health promotion information, including details for self-referrals to maternity care, and mental health support.
 

The service did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. However, they did always involve people in decisions about their care or tell them what had changed as a result.

There was a system to record and investigate complaints. However, records did not evidence action was taken to reduce the risk of the complaint reoccurring.
Since April 2025, the service had recorded 95 complaints, of which 34 had been recorded as formal complaints. The service told us the other 61 complaints had been resolved swiftly and had not progressed to the formal complaint process. However, the service had not identified any themes across these ‘informal’ complaints.
We viewed a sample of 4 formal complaints and found learning was not always identified or evidenced. For example, 1 of the outcome letters referenced the emergency medicines protocol was reiterated to reception staff, however the service did not provide any evidence this had happened.
Another complaint relating to a staff member’s conduct was responded to by the staff member in question. This meant we could not be assured that complaints were investigated in an impartial and fair way, in line with the service’s own policy.

We also found 2 of these complaints had outcome letters, but they did not contain an apology or reference the Parliamentary and Health Service Ombudsman if a complainant was not satisfied with the response from the service.
However, the service had an active Patient Participation Group (PPG) that represented the views of people using the service. Members were encouraged to contribute to meeting agendas and were able to raise questions and discuss issues affecting people. The PPG had reviewed the service’s new website and provided feedback and suggestions to support improvements, demonstrating how the service involved people in the development of services. However, the PPG representative felt the service did not always act on suggestions of the PPG, such as introducing a paper-based survey for those people who were digitally excluded.
 

The service made sure that people could access the care, support, and treatment they needed when they needed it.
People could access the service in different ways, including online, by telephone and in person. The service’s website enabled people to access health and medicines information and to manage some routine requests, such as booking or cancelling appointments, ordering repeat medicines, registering with the service, viewing test results and requesting fit notes.
The service had a process to triage requests for home visits carried out by either a GP or emergency care practitioner. Feedback from people received directly through CQC’s ‘Give Feedback on Care’ indicated it was sometimes difficult to get an appointment. However, we reviewed the service’s appointment system during our onsite visit and found urgent appointments were available the same day and routine appointments could be booked 7 days in advance.
The service had an equality, diversity and inclusion policy in place which set out how staff should promote equality and respect diversity when delivering care and services.
Staff and leaders demonstrated an understanding of the needs of the local population and had developed services in response. They described how they provided opportunities and support for different groups of people, including a dementia café which offered support for people living with dementia and their carers.
However, the 2025 National GP Patient Survey indicated only 48% of respondents had a good overall experience of contacting their GP practice, which is below the local and national average of 70%. Additionally, only 10% of respondents indicated it was easy to contact their GP practice on the phone, compared with a local average of 49% and a national average of 53%. Leaders confirmed they recognised the challenges relating to the service’s phone access and had introduced a new cloud-based telephone system in May 2025 to help address those challenges. This included features such as a call-back facility, to help improve phone access. The service reported it had seen a reduction in complaints around phone access following this change.
 

Staff and leaders actively listened to information about people who were most likely to experience inequality in experience or outcomes and tailored their care, support, and treatment in response to this.
The provider had processes to ensure people could register at the service, including those in vulnerable circumstances such as homeless people and Travellers. The provider was an accredited veteran-friendly service and had a clinical lead for veterans who specialised in supporting the needs of this patient group.
 

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 (CPR). This information was shared with other services when necessary. We reviewed 4 records of people with do not attempt cardiopulmonary resuscitation (DNACPR) documented and found decisions were made in line with the Mental Capacity Act 2005 and other relevant guidance.