Testvale Surgery Also known as Dr Entwisle and Partners

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 75 (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. Care plans reflected physical, mental, emotional, and social needs of people who used the service, including those related to protected characteristics under the Equality Act. Our review of clinical records showed people were supported to understand their condition and were involved in planning for their care needs. People were also involved in decisions about their care. Feedback from local partners, including care homes, highlighted positive aspects regarding the support provided and the delivery of person-centred care.

The service held regular multi-disciplinary team (MDT) meetings with other professionals to coordinate holistic, person-centred care. These meetings were attended by the service, district nurses, community occupational therapists, social services, and the integrated community lead, to discuss people who used the service and how they could holistically support these individuals. The district nursing team highlighted these monthly MDT meetings as the key strength in joint working with the service. They provided an effective forum for sharing information, reviewing complex or vulnerable people, and coordinating care plans and monitoring. The MDT structure supported consistent communication and ensured continuity of care, particularly for people with long‑term or complex needs.

The service made reasonable adjustments to support communication, offering a hearing loop in reception and interpreter and translation services. There were also reasonable adjustments for people who found it difficult to access services, such as offering home visits from paramedics via the primary care network (PCN), or GPs.

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. The service worked in partnership with other services to meet the needs of its population. The service 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.

Appointments were booked with the person’s named GP where possible, and follow-ups were arranged with the same GP to ensure continuity. Efforts were also made to accommodate requests for a specific GP. Some care records included alerts directing staff to book appointments only with a specific GP to ensure continuity of care. A stable clinical team further supported continuity and reduced reliance on temporary locum staff.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs and met the Accessible Information Standard. Leaflets were readily available in the reception area, and posters were displayed to inform people about the service and the various services available to them. People were also provided with clear information on how to access their medical records.

Information to promote the take up of screening and immunisation programmes was available in a range of languages upon request. The service had access to interpreter services, including British Sign Language and this was clearly displayed on a poster in the reception area, as well as recorded within individual care records. In accordance with the Equality Act 2010, the service provided reasonable adjustments to promote accessibility. For example, there was a portable hearing loop for people with hearing impairments and a range of communication formats, including large print and easy-read materials.

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. According to the National GP Patient Survey (2025), 94% of the respondents felt involved in decisions about their care and treatment during their last appointment, which exceeded both the local and national averages.

Complaints were managed in line with the service’s policy. The service made sure that people got an apology when necessary and were directed to the Parliamentary and Health Service Ombudsman if they wanted to take their concerns further. After attending recent complaint management training, leaders shared key learning, leading to improved record‑keeping, including clearer documentation of learning and how that information was shared.

Learning from complaints was evident, for example, there were complaints about long phone wait times, so the service added a call-back feature to its new phone system to address this issue. Since the implementation of this improvement, there had been a decrease in such feedback through Friends and Family Tests, indicating a positive impact. Themes and trends from concerns and complaints were discussed at regular clinical meetings. Minutes from these meetings were available to all staff to ensure they were informed and that any learning was acted upon.

Leaders explained they regularly collected feedback from service users through the NHS Friends and Family Test. They reviewed this information to make improvements and shared the results with both staff and those who used the service. Staff were able to identify changes made as a result of feedback, for example, the service had arranged for a handrail to be added to the corridor, with funding from the service’s patient participation group (PPG), ‘Friends of Testvale Surgery’, after people told the service there was a need for a handrail to be available.

The service made sure that people could access the care, support and treatment they needed when they needed it. Clinical rooms were situated on both the ground and first floors. The facility was fully wheelchair accessible, featuring a lift to provide access to clinical rooms located on the first floor. An automatic door had been installed at the entrance to support ease of access.

People could access the service to suit their needs, for example online, in person and by telephone. In response to the National GP Patient Survey data and from feedback from members of the community the provider had identified changes to improve access to the service. For example, the service changed its booking process, so all same-day appointments were released at 8am, rather than splitting them between 8am and 2pm. This was done to make it easier for people to book on the day appointments and lessen their frustration with the process. Staff could directly book people who used the service into first-contact physiotherapy appointments, which were available every week and based at the service. This formed part of the service’s triage process for those presenting with musculoskeletal concerns.

The service supported people to access care more easily through providing enhanced access arrangements. For example, people were able to secure appointments outside of core opening hours, such as Saturday and evening clinics. This approach offered more flexibility, allowing people, including those working typical office hours, to access healthcare at convenient times. The service operated a dedicated queue for home visit requests, available throughout the day, and maintained an emergency line to prioritise urgent calls from hospitals, other surgeries, care homes, and district nurses. When all same-day appointments were taken, an emergency list was available. People placed on this list were not given a specific GP or appointment time; instead, each clinician would review the list, contact the person, and could arrange in-person visits if necessary.

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.

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 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 service provided various ways to book appointments and order prescriptions, making care accessible for all, especially supporting elderly people and those experiencing homelessness who may struggle with digital technology.

Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. The provider had processes to ensure people could register at the service, including those in vulnerable circumstances such as homeless people and Travellers. For example, people without a fixed address were registered using the service’s address, and staff made efforts to obtain a contact number when possible. Team members were introduced to these people, who were encouraged to visit the service periodically to maintain familiarity with staff and ensure they could readily access support as needed.

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 review of records 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, such as community teams. The service maintained a close working relationship with the local hospice team to deliver coordinated end-of-life care. There were strong support and wellbeing arrangements in place for staff when impacted by the death of people they cared for.

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were made in line with relevant legislation, were appropriate and recorded clearly. We reviewed 5 people who had a DNACPR record. We found 4 had their DNACPR forms correctly saved within their care records, but 1 person did not have a digital copy available. On discussion with the service, it was discovered this person was newly registered from a local care home who already had an existing form held physically at the care home. Despite the DNACPR form not being held within the person’s care record at the time of review, documentation confirmed the GP had discussed and agreed the continuation of this DNACPR decision at the person’s initial review. Following our onsite visit, leaders immediately sent evidence to show the relevant documentation had been appropriately scanned onto the person’s care records. All DNACPR decisions that we reviewed were made in line with relevant legislation, were appropriate, recorded clearly and reviewed as per service policy. The service was transitioning to Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms, which is a broader, proactive document for overall emergency care, not just cardiopulmonary resuscitation. This decision was made by the service to support improved visibility and consistency across records.