The River 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.

People were involved in decisions about their care and treatment. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.

This service scored 86 (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 2010. Our review of clinical records showed people were supported to understand their condition and were involved in planning for their care needs.

We saw evidence of outstanding care planning for people who lived in a care home and people with palliative care needs. The practice held weekly GP led frailty clinics, and care home multidisciplinary team (MDT) meetings and six weekly frailty and palliative care MDT meetings. This ensured the most vulnerable people were supported to have optimal care from the different services they were engaged with and helped prevent admission and readmission to hospital by proactively meeting anticipated care needs. MDT attendees shared an example where the practice team identified and addressed medication‑related issues for a particular person, leading to a more person‑centred plan. The supportive approach included discussions with the family and care staff to clearly explain the process and guide symptom management. The ongoing involvement, reviewing medications, advising on comfort measures, and responding promptly to changes reassured the family and enabled staff to deliver consistent, high‑quality care.

The practice also delivered teaching sessions to their local Primary Care Network (PCN) pharmacists on deprescribing and frailty, with a focus on promoting a person-centred approach to medication reviews. PCNs are groups of GP practices who work together to improve primary care services.

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

We saw the practice worked in partnership with other services to meet the needs of people registered at the service. For example, feedback from the care home providers emphasised a positive partnership with the practice.The provider had weekly care home multidisciplinary team meetings and held weekly onsite GP visits.

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

Information to promote services was available in a range of languages on their website and the practice had access to interpreter services. People were informed 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, with information about the process on site, as well as on the website. 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 a standing agenda item and learning was shared and accessible by all staff members. Staff were able to identify changes made because of people’s feedback.

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

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 for those who were unable to access the second floor and there was a ramp entrance for those who required it.

Staff and leaders were innovative in how they listened to information about people who are most likely to experience inequality in experience or outcomes. Staff and leaders actively used this information to provide exceptionally tailored care, support and treatment in response to this. An example shared by MDT attendees described how the GP adapted the care approach to a specific person’s preferences by involving familiar staff, allowing additional time for care, and using reassurance techniques that the resident responded positively to.

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. Staff understood the importance of providing an inclusive approach to care and adjusted support in people’s experience and outcomes. 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.

Steps were taken proactively to identify vulnerabilities and implement appropriate actions across care settings. For example, for people who lived in a care home, an initial thorough clinical GP led assessment with follow ups as required was undertaken. There was a focus on frailty, polypharmacy and deprescribing to support optimal care and treatment delivery.

In addition, GPs delivered targeted teaching sessions at care homes in response to identified needs, such as sessions about appropriate use of anticipatory medications. We received very positive feedback from care home staff about the service provided.

People were given exceptional support to plan for important life changes, so they could make informed decisions about their future. An example of this came from the care home team feedback describing the practice team as extremely helpful, attending meetings with the Next of Kin and explaining each step of the process to staff so everyone understood the care plan and what to expect, this ensured that care was consistent, compassionate, and well-coordinated, and staff felt fully supported throughout. The proactive involvement gave the family reassurance, supported the nursing team and enhanced communication across the care team.

We found there was a strong emphasis on proactive end of life and future care planning with consistent and well-attended MDT meetings. This information was shared with other services when necessary. We saw evidence of an audit that highlighted the commitment and benefits to having a dedicated GP who has clinical oversight over the complex needs of care home residents, improving people’s health outcomes and reducing healthcare system burden. A specific example came from care home feedback, where the GP identified early signs of deterioration in a resident and initiated additional monitoring, arranged timely community support input, and adjusted the care plan accordingly. As a result, the resident’s condition stabilised and ensured their needs were met promptly and safely within the home.