Limestone 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 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 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 worked in partnership with other organisations to decide how best to respond to any relevant changes in patient’s needs. Patients had access to appointments provided by a range of professionals.

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 service demonstrated an exceptional understanding of the diverse health and social needs of its population, ensuring care was coordinated, flexible and promoted choice and continuity. The practice worked proactively in partnership with a wide range of services to meet local needs, tailoring provision by identifying gaps and establishing and collaborating with community groups to address these.

Continuity of care was prioritised, with clinicians providing consistent, person-centred support, particularly for people with complex needs. Leaders and staff worked collaboratively with partner organisations to deliver inclusive care, adapting approaches to reflect the diversity of the population.

The practice showed a strong understanding of its high-deprivation, multilingual migrant and asylum-seeking population, recognising that frequent GP attendance was often driven by non-medical factors such as immigration uncertainty, language barriers, social isolation and housing instability. In response, the practice co-developed the Dudley Migrant Hub, creating a coordinated system wide pathway rather than relying solely on routine GP appointments. This initiative involved key partners including the Refugee and Migrant Centre, Dudley Council, Public Health, the Mental Health Trust and the Primary Care Network (PCN), and led to clear improvements. The practice could demonstrate that migrant related GP appointments reduced by 39%, missed appointments fell from 39% to 14%, and the number of patients supported directly by the practice reduced, showing care was more effectively shared across services.

The practice also demonstrated strong ongoing partnership working through the Pharmacy Independent Prescribing Pathfinder model. This delivered 639 consultations, with almost all recorded on the same day. Most patients were managed directly by the prescribing pharmacist, with very few requiring onward referral, supported by GP oversight and clear governance.

Despite the complexity of this work, the team showed high levels of commitment and accountability. Through effective partnership working and innovative service development, the practice ensured patients received timely, responsive and high-quality care and support.

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

Information promoting health and wellbeing was readily available within the practice, and the website provided helpful resources to support health awareness and promotion. Patients were given access to clear information and signposting to help them understand how to access services. Interpreter services were available to support patient communication needs.

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. This was clearly displayed in a range of languages.

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.

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 above the local average of 84% and just below the national average of 87%.

The practice used the Friends and Family Test (FFT) to gather patient feedback. The results between January and December 2025 showed 82.6% of patients was extremely likely/likely to recommend the practice to friends and family.

We spoke with patients on the day of the onsite assessment and received positive feedback on the care and treatment people received. We also saw evidence of the practice’s commitment to patient feedback through the display of a ‘you said, we did’ board, which highlighted actions the practice had taken in response to patient feedback.

There was an active Patient Participation Group (PPG) in place. We spoke with 2 members of the group, who told us they were actively involved in the practice and supported health campaigns and gathering patient feedback through questionnaires.

Complaints were managed in line with the practice’s policy, and learning from complaints was evident. Staff were able to describe changes made as a result of patient feedback. However, a review of a sample of complaints showed that these did not always include information about escalation to the Parliamentary and Health Service Ombudsman (PHSO). We discussed this with the practice who agreed to take this action forward.

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

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 above the local average of 48% and in line with the national average of 53%. Patients could access appointments by phone, online and face to face. Patients who had a request for an emergency appointment were seen the same day. Feedback from patients we spoke with on the day of the assessment highlighted the good service they received. 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.

The practice used a cloud-based telephony system for patient calls which were consistently monitored. Data showed that monthly reviews of the telephone system were undertaken. For example, in February 2026 the practice received 3,028 calls, with 75% answered with an average waiting time of 3 minutes and 1 second. As part of our assessment, we reviewed the practice’s appointment system. We found that routine appointments were available on average within 10 days. Urgent same day appointments were also available, with capacity observed during both the morning and afternoon on the day of the assessment.

In response to demand and ongoing access review, the practice increased GP capacity by 6 additional clinical sessions, jointly funded with the PCN. The practice demonstrated a strong focus on equitable access by implementing targeted systems for patients at risk of barriers to care, including a structured emotional distress alert and short notice GP access process supported by a policy. This enabled consistent, compassionate responses, timely GP access, and rapid escalation where risk was identified, ensuring access was adapted for vulnerable cohorts rather than relying solely on standard pathways.

Further improvements through the GPIP programme strengthened access by reducing avoidable demand, improving signposting and communication, and protecting same day capacity, resulting in over 67 hours of reduced administrative workload annually.

The practice provided extended hours appointments Monday to Thursday evening until 8pm. When the practice was closed patients were able to contact 111. Pre-booked appointments were available on weekday evenings and on Saturday through an arrangement with other local GP practices.

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 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).

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. For example, improving signage in the building. The provider had processes to ensure people could register at the practice, which was recognised as a ‘Safe Surgery’, ensuring that lack of identification, a fixed address or immigration status was never a barrier to accessing care.

The practice population was within the lowest deprivation and included a high number of migrant patients whose first language was not English. There was also a higher proportion of older patients and people living with long‑term conditions. Leaders recognised that this created challenges, including increased demand, the need for longer appointments, and difficulties in engaging patients with health screening and immunisation programmes.

Despite these challenges, the practice demonstrated ongoing commitment to reaching all members of its community, recognising the diverse needs, experiences and barriers faced by patients. The practice implemented tailored strategies to meet the needs of its population and monitored outcomes to ensure services were responsive and effective. For example, leaders recognised that digital exclusion continued to be a barrier for some patients in accessing online appointment systems. In response, the practice held an NHS App support day to help patients improve their digital access and confidence. The practice also had 2 designated digital champions available to support patients on an ongoing basis. To prevent exclusion, the practice continued to provide non‑digital access routes for appointments and services, ensuring equitable access for all patients. The practice demonstrated proactive system leadership in supporting the local migrant population by undertaking outreach work at local hotels to register eligible patients and improve access to care. They worked closely with Primary Care Support England (PCSE) to review and validate patient lists, recognising the challenges of a highly transient population and ensuring records remained accurate, safe and reflective of current need.

The practice showed a strong commitment to equitable care by using a proactive approach aligned with Core20PLUS (which focuses on the most deprived 20% of the population). It used targeted searches, repeat reminders, personalised and translated messages, opportunistic contact, and partnership work which moved beyond standard recall systems to address known access barriers.

This approach resulted in measurable improvements in outcomes, including breast screening improvements (16% to 65%), bowel screening (66% in 2024), and lipid target achievement (48% to 52%), demonstrating sustained progress in reducing inequalities.

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

There were systems in place to ensure staff kept up to date in training relating to the Mental Capacity Act and Deprivation of Liberty. We found that staff had completed the required training.

Our records review showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms were in place and available within the clinical record.