Cumberland House Surgery

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• 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 assessed all the quality statement in this key question. At our last assessment, we rated this key question as good. The rating remains good following this assessment.

The provider understood their patient population and they identified and made changes to improve their service where required. People who used the service provided positive feedback with regards to their ability to access care and treatment. CQC received feedback from 34 patients and 97% reported positive experiences with feedback indicating satisfaction with care and treatment, access and interactions with staff. Responses to the GP National Patient Survey for access showed the practice was above the national averages. People were able to access the service readily and in a way that met their needs. Clinicians were available to see people on-the-day for urgent appointment requests. Staff were trained to direct people to the most appropriate service to meet their needs. Leaders proactively sought ways to address any barriers to improving people’s experience and outcomes. People who used the service were supported to make decisions about their future care.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We found examples of outstanding practice in how person-centred care was delivered. Services were established to meet the specific needs of patients. For example, holistic reviews of housebound people and people who frequently attended Accident and Emergency took place to minimise the risk of them having to go to hospital through the development of a care and support plan. The provider was working individually and with the Primary Care Network (PCN) to provide and develop services in response to identified needs. For example, a GP from the practice had established a perinatal clinic which resulted in people receiving a timely service to review their needs by the same health care professional. A women’s health clinic was being established by a GP at the practice to improve access for women to services such as menopause care and contraceptive implants. The practice was a veteran friendly practice. The practice worked with the PCN to provide a ‘Full Circle Programme’ that supported people at every stage in their lives by working with local health and care services, advertising these services and supporting people to access them. For example, educational events were provided giving information about specific aspects of health such as menopause health, living well and counselling services. The provider had contributed to a roadshow set up by the PCN and other providers to provide information, health and well-being activities and health checks. Also, through the PCN a befriending service had been set up and working with a local college, a counselling service had been established. Care co-ordinators and social prescribers supported people to access services to support their individual health and social care needs. Feedback from the National GP Patient Survey showed 91% of people (compared to 91% nationally) reported they were involved in decisions about their care and treatment and 91% of people (compared to 90% nationally) reported that their needs were met. The practice liaised with external professionals to discuss and plan patient care and treatment so that people’s individual needs could be met.

Feedback from people who used the service in the National GP Patient survey showed that 91% of respondents (compared to 90% nationally) felt the healthcare professional they saw had all the information they needed about them during their last general practice appointment. Recent feedback from people on the NHS website (these reviews were unvalidated by CQC) described receiving continuity of care and GPs being aware of peoples ongoing health needs. The practice worked in partnership with other services to meet the needs of its patient population and community, systems were in place to share information between services and the same clinicians visited residential services for people to promote continuity. The service delivered care to meet the needs and preferences of different people, including those most at risk of a poorer experience, for example by providing holistic reviews to people with poor mental health and reviews of people with a learning disability. The service carried out reviews of people who were housebound to identify and plan for their care. The service worked closely with the social prescribing team to co-ordinate care and support for people. Regular meetings were held with health and social care professionals to identify and respond to people’s needs.
 

Staff communicated and provided information in a way that helped people to understand their care. People’s individual needs to have information in an accessible way were identified, recorded and shared. Information was adapted to meet people’s specific needs, for example through the use of translation services for people who did not speak English as a first language. Support was provided for people who had difficulty using digital services. People were provided with sufficient information about their health and treatment options for them to make an informed decision. Safety netting advice was provided when patients were at risk of deteriorating. The practice website contained NHS information about health conditions and support services that people could use. Staff had received training on information governance and had access to policies to support information governance which included General Data Protection Regulation (GDPR). A quarterly newsletter was produced that provided information about the service, such as any changes, appointment system and help in the community. Following feedback from Healthwatch regarding menopause care the service responded by improving awareness by putting in place a menopause information board in reception, one of the GPs gave a talk for people on menopause and staff received training from a GP at the practice with a specialist interest in menopause on the current management guidelines.

Patients responded positively in the annual National GP patient survey for questions related to the healthcare professional being good or very good at listening to them and involving them as much as they wanted in decisions about their care. Feedback shared with CQC directly by people who used the service was positive with regards to people feeling listened to and involved in decisions. The provider monitored patient views through a variety of sources, including through the NHS Friends and Family Test. They produced a monthly report for patients of the results of this feedback and actions to improve services. NHS Friends and Family Test results for June 2024 – April 2025 showed there had been 3,869 responses with 95% reporting that the service was very good or good. The provider took action when patient feedback suggested improvements were needed. For example, the National GP Patient survey showed that 88% (national average 92% ) of respondents stated that during their last appointment, they had confidence and trust in the healthcare professional they saw or spoke to. The provider told us that to address this they had made changes to the appointment system so that people saw the same clinician where possible, to promote continuity of care.

Information was available at the service and online so that people knew how to give feedback about their experiences of care and support, including how to make a complaint. We reviewed a sample of 3 complaints which showed appropriate action. We noted that a letter was not always sent to the complainant to formally demonstrate the action taken and to direct patients to the Parliamentary Health Service Ombudsman should they not be satisfied with how the complaint was managed. The provider took action to address this following the assessment.

There was a process for learning from complaints and sharing any actions needed across the whole staff team. Staff were knowledgeable about the complaint process and how to support patients to make a complaint. However, some staff told us that they were not always notified about complaints and the outcome. This was brought to the attention of the provider.

People could access care, support and treatment when they needed it and in a way that reflected their needs. Digital flags were used within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff told us they provided opportunities and support for different groups of the patient population to overcome health inequalities. For example, the service supported people that did not have online access. Registers of vulnerable patients were maintained to identify them and provide services, such as chronic disease reviews of housebound people. There was information available to support people to understand how to access the service. Appointments were available outside of school and usual working hours. People could access appointments online, over the phone and in person. Appointments with a GP were made via an electronic appointment request form, however, people could still request an appointment by phone or in person and support was provided to people to complete the request. Senior clinicians triaged online requests so that people with immediate needs were seen in a timely manner. There were systems and processes in place to prioritise people presenting with the highest need. Longer appointments were available to support the needs of patients. The premises had been assessed to ensure they were accessible for people who were physically disabled.

The responses of people to the National GP Patient Survey were above national averages. The percentage of respondents who responded positively to their overall experience of contacting the practice was 72% (compared to 67% nationally). 67% of respondents (compared to 66% nationally) felt they waited about the right amount of time for their last appointment. 55% of patients (compared to 50% nationally) found it easy to contact the practice by phone. 62% of patients (compared to 48% nationally) found it easy to contact the practice using the website. 91% (compared to 83% nationally) found the reception and administration team helpful and 87% (compared to 83% nationally) knew next steps after contacting the practice. Feedback from patients on the NHS website (these reviews were unvalidated by CQC) describedaccess to the service as quick and efficient.

The provider continually monitored access to ensure it continued to meet patients’ needs and introduced changes to improve access in accordance with the findings. For example, the length of appointment times for clinicians had been increased in response to a review of access arrangements. A digital telephone system had been introduced that allowed the service to monitor and respond to peak times of demand for inbound calls. An acute visiting service (for people experiencing symptoms that required immediate medical attention but were not severe enough for hospital admission) had also been put in place across the PCN to support urgent care needs. Overall, staff were positive about patient care although some considered improvements should be made to the appointment system.

Leaders addressed barriers to equity in people’s experience and outcomes. The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and Travellers. Staff had been provided with training on supporting people with a learning disability. Training for all staff on supporting people with autism was planned. A register was in place to identify vulnerable people such as people with a learning disability and promote access to services, for example an annual review. Staff understood the importance of providing an inclusive approach to care and made adjustments to promote this. Staff had completed training in equality, diversity, and inclusion and further training was planned. Staff had completed training from the LGBT (lesbian, gay, bisexual, and transgender) Foundation, called 'Pride in Practice' and was working towards accreditation. We did not see evidence of discrimination when staff made care and treatment decisions. The service took steps to address inequalities in service provision by setting up a coil fitting and menopause clinic to address the long waits for these services.

Available data showed that people experienced similar outcomes when compared to services locally and nationally. The results of the National GP patient survey showed that 91% of respondents (compared to 90% nationally) felt their needs were met during their last general practice appointment. We noted that 69% of people (compared to 74% nationally) described their overall experience of the practice as good. The provider told us how they had made changes to the service to address this and to improve how they collected patient feedback. The providers own survey results from 2025 showed 92% of people (127 responses) responded good or excellent to the question 'Based on your last visit to the doctor, please rate the treatment provided. Recent feedback from people on the NHS website (these reviews were unvalidated by CQC) described being treated respectfully.

 

People were provided with information to make informed decisions about their current and future care and treatment. 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. Multi-disciplinary meetings were held to discuss supporting people receiving end of life care, including those who had recently been diagnosed with cancer who were offered a review with a GP. Patients with high frailty and two or more medical conditions or diseases had annual holistic reviews of their care that included planning for the future. Reviews of housebound patients included advanced care planning and discussions around Do Not Attempt Cardiopulmonary Resuscitation decisions.