Drs Dawes, Narasimhan and Spiller

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 patients including those related to protected characteristics under the Equality Act. 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 practice worked in partnership with other organisations to decide how best to respond to any relevant changes in patient’s needs. Patients had access to appointments provided by a range of professionals.

The practice used patient feedback to identify areas for improvement and made necessary adjustments to ensure patient care was optimum. The patient participation group (PPG) were positive about their involvement with the practice and assured us any suggestions were taken seriously to improve patient care.

Patient satisfaction scores in the GP National Patient Survey were higher than local and national averages, particularly in areas relating to patient-centred care. For example, 90% said the healthcare professional they saw or spoke to was good at treating them with care and concern during their last general practice appointment. This was above the local average of 82% and above the national average of 86%,

Patients had access to appointments provided by a range of clinicians. The practice used patient feedback to identify areas for improvement and made necessary adjustments to ensure patient care was optimum.

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 practice 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. Systems supported smooth transitions between hospital and community care, and staff maintained oversight of referrals and results.

There were established mechanisms for engaging with the community healthcare provider. We saw the practice worked in partnership with other services to meet the needs of its patient population. For example, there were weekly multidisciplinary meetings (MDT) held with community health teams to ensure coordinated care for vulnerable people.

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. The practice produced a regular newsletter to keep patients informed of changes within the practice, services available, and local initiatives. 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.

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 92% of patients say the healthcare professional they saw or spoke to was good at listening to them during their last general practice appointment. This was above 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 December 2025 showed 95% of patients was extremely likely/likely to recommend the practice to friends and family.

We spoke with patients on the day of the onsite assessment and received positive feedback on the care and treatment people received. We also saw evidence of the practice’s commitment to patient feedback through the display of a ‘you said, we did’ board, which highlighted actions the practice had taken in response to patient feedback.

There was an active Patient Participation Group (PPG) in place, with meetings held every 2 to 3 months. We spoke with 5 members of the group, who told us they were actively involved in the practice and supported both the practice and its patients by signposting to local services and contributing to health campaigns such as flu, COVID‑19 and cancer awareness.

We saw evidence in the reception area promoting the PPG, and members also supported the practice in producing its newsletter and hosting health‑related events. Friends and Family Test results were shared with the PPG to explore opportunities for improvement and to ensure patient feedback informed service development.

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.

The service made 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 friends and family feedback from patients. The GP national patient survey showed 88% of respondents found it easy to get through to the provider by phone. This was significantly higher than the local average of 48% and the national average of 53%.

Patients could access appointments by telephone and online. The practice had arrangements in place for prioritising patients. Staff were trained to book appointments with members of the practice clinical team or signpost patients to other appropriate services. Patients were given the option of a face to face or telephone appointment. Patients who had a request for an emergency appointment were seen the same day and request for home visits were reviewed and carried out if deemed appropriate.

The practice used a cloud-based telephony system for patient calls. Call volumes were uncapped and consistently monitored. Data showed that monthly reviews of the telephone system were undertaken. For example, in January 2026 the practice received 9,962 calls, with 69% answered with an average waiting time of 3 minutes and 43 seconds. A call back facility was in place to reduce waiting times for patients attempting to contact the practice. Records indicated that 522 patients requested a call back during January, of which 513 were successfully completed. As part of our assessment, we reviewed the appointment system and could evidence same day appointment availability.

The practice website provided patients with clear information on 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 from 8am until 6.30pm. The practice provided extended hour appointments on Tuesday mornings from 7am. Pre-booked appointments were available on weekday evenings and on Saturday and Sunday through an arrangement with other local GP practices. When the practice was closed patients were able to contact 111.

Treatment rooms were available on the ground floor, disabled parking and disabled toilet and baby changing facilities were also 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. Wheelchairs and walking aids were available to assist patients if required.

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.

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

People we spoke with on the day of the assessment, as well as feedback received through our Give Feedback on Care process, were positive about their experience of the practice. Patients told us it was easy to obtain an appointment, and described staff as professional, efficient and understanding. They also reported that staff put them at ease and provided a high standard of service.

Staff treated people equally and without discrimination. Leaders proactively sought ways to address any barriers to improving people’s experience and understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes.

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.

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, for example, those on the practice palliative care register.

There were registers held for those patients who were vulnerable who were on the palliative care register or at the end of their life. We found that clinicians understood the requirements of legislation and guidance when considering consent and decision making and saw that consent was documented.

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. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms were in place and available within the clinical record.