Church Lane 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

People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. People were involved in planning their care and understood options around choosing to withdraw or not receive care. Staff and leaders were innovative in how they listened to information about people who are most likely to experience inequality in experience or outcomes. The provider had proactively engaged Care Coordinators to support patients whose circumstances may make them vulnerable. For example, a befriender for those aged over 75 years, identification and support of frequent attenders at practice and hospital and support for people who had been former members of the armed forces.

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.

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. The practice invited all newly registered patients who were either aged over 50 years, on repeat medicines or had a long-term condition to have an appointment with a GP to ensure their repeat prescriptions and management of long-term conditions was timely. Patients were also involved in decisions about their care. The National GP Patient Survey data showed 98% of patients felt involved in decisions about their care (national average 91%).

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. For example, the service held regular multi-disciplinary team meetings to discuss patients whose circumstances may make them vulnerable, these were attended by other professionals like Community Matrons and District Nurses.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. The practice had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard. Patients were informed as to 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. National GP Patient Survey data showed 98% of patients said the last healthcare professional they saw or spoke with was good at listening to them (national average 87%). 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. For example, following a delay in administering a childhood vaccination in the recommended timeframe, the system for identifying newly registered babies was revised to enhance monitoring and ensure timely invitations.

The service made sure that people could access the care, support and treatment they needed when they needed it. In response to patient feedback with regard to accessing same day appointments and difficulties accessing the practice by phone at 8am for an appointment, they had implemented a triage system. All appointment requests were triaged the same day by a GP. People could access the service in a way to suit their needs for example online, in person and by telephone. The provider was monitoring staff feedback and patient feedback via the National Friends and Family Test and the PPG. Feedback from both staff and patients was very positive. The service was open 8am to 6.30pm Monday to Friday with extended access Sundays 9am to 1.30pm. Treatment rooms were available on the ground floor.

The National GP Patient Survey data showed 79% of patients reported a positive experience contacting their practice (national average 70%) and 62% said it was easy to get through on the telephone (national average 53%).

Staff and leaders were innovative in how they listened to information about people who are most likely to experience inequality in experience or outcomes. Staff and leaders actively used this information to provide exceptionally tailored care, support and treatment in response to this. The provider had proactively engaged Care Coordinators to support patients whose circumstances may make them vulnerable. For example, a designated Care Coordinator maintained regular contact with a local care home, conducting weekly check-ins to discuss individuals of concern and address any outstanding issues, such as prescription management.

One of the Care Coordinators provided a befriending service for patients aged 75 years and over who had not recently engaged with the practice or were identified as requiring additional support. Depending on individual preferences, patients were contacted on a weekly, or monthly basis, with up to 6 patients seen face to face each week. This initiative offered companionship, practical advice, and signposting to relevant services or clinical care. Several examples demonstrated the positive impact of this service. For instance, during a conversation with one patient, the Coordinator reminded them about the annual flu and COVID-19 vaccinations. The patient, who was housebound, had previously been unaware they were eligible and had missed vaccinations in prior years. The Coordinator arranged a home visit and ensured the patient’s record was updated for future contact. In another case, a patient received guidance on available allowances and parking permits and was signposted to a local community organisation, enabling them to access entitled support. Patients were also referred to local community hubs to encourage social interaction, and those presenting with medical concerns, such as low mood, were referred directly to a clinician for follow-up.

The provider had established effective mechanisms for identifying individuals who may be vulnerable. As an accredited Veteran Friendly Practice, they demonstrated a proactive approach to supporting former members of the armed forces. The Advanced Clinical Practitioner (ACP) developed and maintained a dedicated register of veteran patients and actively sought to identify individuals with military service to address their mental and physical health needs. Outreach efforts included sending targeted text messages, incorporating relevant questions into new patient registration forms, and publishing informative articles in their regular newsletters, which featured links to support organisations. Feedback from one patient indicated that the support received had been ‘life-saving’, with the ACP providing empathetic listening, facilitating access to appropriate services, and signposting to organisations previously unknown to the patient, ultimately leading to accurate diagnosis, treatment and social support. All patients who identified as veterans received a welcome pack containing information on housing support and mental health services, for example.

The practice had conducted an audit to identify patients who were frequent attenders, both at the practice and at the Accident and Emergency department. Following this, all identified patients were contacted, and one individual was found to require additional support. In response, the practice arranged weekly appointments with a GP to address the patient’s concerns comprehensively and regularly. This approach not only helped reduce unnecessary practice and hospital attendances but also provided a more supportive and consistent care experience for the patient.

Feedback provided by people using the service, both to the provider as well as to CQC, was positive. On the latest National GP Patient Survey, 99% of patients said they had confidence and trust in the last healthcare professional they saw or spoke with and 89% of patients responded positively to their overall experience of their GP practice (national average 75%). 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 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 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 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 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.