City Way 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 patients’ needs, and that staff treated patients equally and without discrimination.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed.

This service scored 68 (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 patients were at the centre of their care and treatment choices, working in partnership with them to respond appropriately to any changes in their needs.

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

We saw the practice worked in partnership with other services to meet the needs of its patient population. The practice had tailored its services to meet the diverse needs of its community, for example, building relationships with community groups to promote the take up of screening programmes. There were established mechanisms for engaging with the community healthcare provider.

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

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 practice’s complaints procedure leaflet for patients explained that an acknowledgement response would be issued within 3 working days. This is consistent with the NHS Complaints Regulations. However, the practice’s complaints policy stated an acknowledgement response would be issued within 7 working days. This inconsistency created a contradictory message for staff and patients and increased the risk that complaints might not be handled within the required regulatory timescale. Following the assessment, the practice updated its complaints policy to align with the NHS Complaints Regulations and shared the revised version with all staff.

The practice encouraged patients to share feedback and ideas, or raise complaints about their care, treatment and support. They involved patients in decisions about their care and told them what had changed as a result.

We reviewed complaint records and saw that the practice had an established system to respond to and learn from complaints. The practice acknowledged where improvements were needed and implemented changes. For example, after receiving a complaint about a patient not being informed of a change to their appointment time, staff were given feedback and guidance to help ensure that any future appointment changes were clearly communicated to patients.

There were processes to monitor and respond to changes in patient demand for services and clinical risks. There was a triage system to assist staff to prioritise patients according to clinical needs.

The practice undertook regular monitoring of its telephone queue performance to identify areas for improvement and enhance patient access. Data provided by the practice showed a reduction in missed or dropped calls, falling from 1,660 in August 2023 to 541 by December 2025. Average queue waiting times also improved, decreasing from 42 minutes in 2023 to 13 minutes in 2025. Staff told us these improvements followed actions by the practice, including the recruitment of additional reception staff and further training to support more efficient call handling and patient communication.

Treatment rooms were available on the ground floor and the practice had a ramped entrance for easy access.

The practice offered extended hours appointments from 7am to 8am every day except Wednesdays.

Patients reported disparities in their experiences and outcomes. Results from the national GP patient survey (2025) identified 54% responded positively about their overall experience of the GP practice which was below the national average of 69%. Results also identified 35% of respondents responded positively to how easy it was to contact the practice on the phone. This was below the national average of 52%.

Feedback received by the Care Quality Commission through the “Give Feedback on Care” form on its website reflected these results. Patients reported that they were not always able to access appointments when needed and were at times informed that the practice was “at capacity,” meaning it could not accept new appointment requests. They also described difficulties getting through to the practice by telephone, often experiencing long waiting times.

Patients also reported receiving inconsistent information when trying to book appointments. For example, the automated phone message directed them to complete the online form, but the form stated the practice was at capacity and not accepting new requests. When they telephoned the practice, they were told it was not at capacity and advised to complete the form again. After doing so, some patients were then informed that no appointments were available for new health concerns.

Some patients provided positive comments about the appointment booking system, stating they did not have difficulties in obtaining an appointment in a timely manner.

Staff told us they monitored demand and access and increased capacity when needed, for example by hiring locum clinicians. They also explained that they were actively trying to recruit additional permanent staff as part of an ongoing recruitment drive.

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.