Mowbray House 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 the service met people’s needs, and 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 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 did not look at Person-centred Care during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Care provision, Integration and continuity during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Providing Information during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Listening to and involving people during this assessment. The score for this quality statement is based on the previous rating for Responsive.

The service was exceptional at ensuring people could access the care, support and treatment they needed when they needed it.

The service performed better than the national average in the results of the 2025 National GP Patient Survey. This showed people could access the service when they needed it in a way that suited their needs, such as by telephone, in person or through the service’s website. For example, 85% of respondents to the survey described their overall experience of contacting this service as being good, compared to a national average of 72%. In response to feedback from people who used the service, staff had made changes to improve access. For example, changes to GP-initiated follow-up appointments improved continuity, enabling patients to be reviewed by the clinician overseeing their ongoing care and supporting safer, more coordinated management of long-term and complex conditions. Treatment rooms were available on the ground floor, and a ramp and automatic door had been fitted to the entrance to ensure ease of access to the service.

We saw that the practice had improved responsiveness for patients on the Gold Standard Framework register as a result of a quality improvement project. (The Gold Standards Framework (GSF) is a practical system used by GP practices to provide high-quality, proactive care for patients in their final year of life.) Patients and their families on the register with the most serious needs now have their telephone numbers tagged within the practice phone system. This ensured calls were prioritised and moved to the front of the queue, providing faster access to support and reducing stress and delays for patients and carers during critical periods.

The provider described an example of improvement in equity when it reviewed its own practice-level data to understand how well the farming population was represented within its clinical coding. This analysis showed that their existing coded data was not truly representative of the local farming community across practices. To address this, they developed and published a patient questionnaire asking individuals to self-identify as farmers. Where patients confirmed they were farmers, this information was written back into the clinical system and appropriately coded. As a result of this intervention, they identified an increase of 126% in the number of patients coded as farmers. A pop-up was added to the clinical system stating, ‘this patient is a farmer’ and messaging within that alert to inform staff that these patients may present urgently and that flexibility when offering appointments may be required.

Staff and leaders were innovative in how they listened to information about people who were most likely to experience inequality in experience or outcomes. They actively used this information to provide exceptionally tailored care, support and treatment.

Staff and leaders actively listened to information about people who were most likely to experience inequality in experience or outcomes. They tailored their care, support and treatment in response to this.

Staff treated people equally and without discrimination. Leaders proactively sought ways to address any barriers to improving people’s experience and worked with local services, including within the voluntary sector, to address any local health inequalities. For example, the practice had made a concerted effort to improve uptake of NHS Health Checks through the introduction of regular monitoring, monthly audits of invited and attended patients, and a proactive approach to patient engagement. This allowed for earlier identification of cardiovascular risk factors such as high blood pressure, raised cholesterol, obesity stroke, kidney disease, and diabetes.

Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes, for example, the practice pharmacy team offered home visits where necessary, to better engage isolated patients. Staff followed processes to ensure people could register at the service, including those in vulnerable circumstances such as homeless people and Travellers. Staff used systems to capture and review feedback from people who used the service, which included those who did not speak English or have access to the internet. This was reflected in the feedback shared from people who used the service, which was predominantly positive.

There was a culture of understanding the importance of continuity of care at the practice. This meant that although patients could be offered the next available appointment with any available clinician, there was a golden thread of continuity woven through decisions, analysis of test results and recalling patients to improve diagnostic accuracy and patients’ experience of care.

We did not look at Planning for the future during this assessment. The score for this quality statement is based on the previous rating for Responsive.