Cape Hill Medical Centre

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 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.

Although national survey results indicated some aspects of patient-centred care were rated slightly below national averages, clinical records demonstrated that patients were routinely involved in discussions and decisions about their and treatment. Staff had been trained in equality and diversity, consent, deprivation of liberty safeguarding and mental capacity.

Care plans reflected physical, mental, emotional, and social needs of patients including those related to protected characteristics under the Equality Act.

Patient satisfaction scores in the GP National Patient Survey were slightly below local and national averages, particularly in areas relating to patient-centred care. For example, 71% of people said the healthcare professional they saw or spoke to was good at considering their mental wellbeing during their last general practice appointment. This was in line with the local average of 71% and the national average of 74%.

A review of clinical records confirmed that patients were supported in understanding their conditions and were actively involved in planning and making 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 practice had patients registered from a range of local nursing homes within the PCN. We sought feedback from some of the care homes regarding the GP service provided and we received positive feedback from all the homes we spoke with. They stated they valued their professional working relationship, highlighted the accessibility to clinical staff when needed. Weekly ward rounds were held and clinical staff supported the patients’ families, reviewed DNACPR forms, regularly reviewed medicines and provided clinical advice to their staff.

The practice understood the needs of its local population and was taking action to develop services in response to those needs. The had an in house social prescribing team who connected patients with non-medical community support. The social prescribing lead at the practice, also supervised the PCN social prescribing team. The practice worked with a third party, who provided clinical pharmacy support to monitor people and the prescribing of medicines, We saw the practice worked in partnership with other services to meet the needs of its patient population.

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.

The practice website included useful information on health awareness and promotion. Information and resources were available for patients to support them to understand how to access services.

Regular searches were completed to identify young people approaching their 18th birthday who were leaving care. A letter was sent to patients that had been in care as a child offering support and signposting them to local services for support and advice.

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.

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 83% of patients said the healthcare professional they saw or spoke to was good at listening to them during their last general practice appointment. This was in line with the local average of 84% and the national average of 87%.

The practice used the Friends and Family Test (FFT) to gather patient feedback. The results for May 2026 showed 72 out of 80 of patients who had completed the FFT said the practice was very good/good. Some of the positive comments the practice had received included patients felt heard and acknowledged and staff were very efficient.

We spoke with patients on the day of the onsite assessment and received positive feedback on the care and treatment people received.

The practice had not had an active patient participation group (PPG) since the pandemic. We found notices inviting patients to join the PPG were on display in the reception waiting area in a range of languages. There was also information available on the practice website.

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. Minutes of meetings demonstrated complaints were a standing agenda item and were discussed with the practice team to ensure learning was shared to improve patient satisfaction.

The service did not always make 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 26% of respondents found it easy to get through to the provider by phone. This was considerably lower than the local average of 48% and the national average of 53%. The practice team had discussed the results of the survey and had an action plan in place. For example, the number of staff answering calls had been increased at peak times to reduce call waiting times and improve telephone access.

Feedback we received from patients highlighted the difficulties they faced in accessing the practice, with numerous negative comments about the unhelpfulness of the reception staff.

Patients could access appointments by phone and online. The practice used an online triage system where all requests for a GP appointment were directed to the care navigators to review the request to make a decision regarding which clinician was appropriate for them to see.

Patients were given the option of a face to face or telephone appointment. Staff were available to support patients who were digitally excluded to complete the form. Patients who had a request for an emergency appointment were seen the same day. A supervising GP was available throughout the day to provide support to staff on the appropriate clinical pathways to be used to ensure patients received the care and treatment they required. 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.

Appointments with a GP were available throughout the week. Extended appointments were available for vulnerable people and those with a learning disability. The practice provided extended hours appointments on Monday and Wednesday evening until 8pm. When the practice was closed patients were able to contact 111. The practice offered appointments from a variety of additional clinical staff for example advanced nurse practitioners, practice nurses and pharmacists. Pre-booked appointments were available on weekday evenings and on Saturday through an arrangement with other local GP practices.

Treatment rooms were all situated on the ground floor and there was disabled parking and disabled toilet facilities available.

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). We saw examples where the practice had removed barriers for improved patient experience. For example, the practice premises had a hearing loop in place and access to interpreters was available. We found the premises user friendly for people with a disability.

The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people. 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.

The practice was involved in an asylum seeker health project. The project provided improved access and continuity of care for newly registered asylum seekers. Health screening and a dedicated weekly clinic with a GP was held. The project was also supported by the social prescribing team as well as the mental health and hospital outpatients’ teams to ensure a co-ordinated package of care was in place.

People with learning disabilities and poor mental health experienced additional care through annual reviews. People with dementia were referred to appropriate services where required.

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.

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. We were told that the practice held multidisciplinary meetings to share and discuss information relating to patient care and treatment. There were registers held for those patients who were vulnerable who were on the palliative care register or at the end of their life.

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. We reviewed a random sample of 2 clinical records of people who had a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form in place and found they were relevant, completed and available within the clinical record