Fell Cottage 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 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.

Feedback from staff was consistent, they said they worked well together as a team to provide good care for patients.

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. The practice had tailored its services to meet the diverse needs of its community. There were established mechanisms for engaging with the community healthcare provider.

We sought feedback from the care home which the practice was aligned to support. They told us that access to the practice was good and the practice responded well to their requests for home visits. A dedicated GP attended on a weekly basis, to continue to strengthen joint working. Clinical staff spent time with patients and built trusting relationships, which helped enhance the quality of care delivered.

There was a process for identifying people with extra healthcare and communication needs. Alerts were added to their clinical records so that staff were immediately aware of how to assist them.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff communicated with patients in a way that helped them to understand their care, treatment and condition, and any advice given. They helped patients and their carers find further information and access community and advocacy services. They had systems in place to access interpreter services. 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.

We saw complaints were managed in line with the practice’s policy. The practice had a positive approach to receiving feedback and complaints. From the complaints we reviewed we saw the practice had responded to feedback appropriately, openly and in a non-defensive manner. Learning from complaints was evident and staff were able to identify changes made as a result of patient feedback, including complaints. Staff demonstrated an understanding of their Duty of Candour and the importance of being open, honest, and transparent when things go wrong.

The practice routinely asked patients to complete Friends and Family Test (FFT) feedback forms and reviewed the feedback for any trends or themes. In the 3 months November 2025, December 2025 and January 2026 prior to the assessment, the NHS Friends and Family Test results for the practice scored a good or very good rating consistently of 90% or above. We saw the practice had recently changed the electronic programme to collect this data and the analysis of the data was in progress.

Results from the National GP Patient Survey showed the practice performed above the national average, achieving 97.5% of respondents who stated that during their last appointment, the healthcare professional was very good or fairly good at listening to them, (the national average was 87%).

The service made sure that people could access the care, support and treatment they needed when they needed it. Services were delivered which ensured flexibility, choice and continuity of care.

People could access the service in a way that suited their needs including online, in person and by telephone. To further support equitable access, leaders implemented surgery opening and appointment start times from 7.30am, helping to accommodate patients with different schedules. Telephone lines opened at 8am.

In response to feedback from the National GP Patient Survey and members of the local community, the provider identified and implemented changes to improve access to the service. Leaders also considered staff feedback regarding demand for certain appointments at specific times and adjusted appointment rotas accordingly to better meet patient needs.

Results from the National GP Patient Survey showed the practice performed much better than national averages in several areas concerning access. The percentage of respondents who responded positively to how easy it was to contact their GP practice on the phone was 78.4% compared to the national average of 52.9%. The percentage of respondents to the same survey who responded positively to the overall experience of contacting their GP practice was 86.9% compared to the national average of 69.6%.

The premises was wheelchair accessible, and all patients were seen on the ground floor. The practice had a hearing loop.

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. According to the National GP Patient Survey carried out between January and March 2025 patients were satisfied with access to the practice. Figures showed the practice performed well above national averages in the access indicators. Leaders told us they regularly reviewed access and appointment information.

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 and Travellers.

Systems and processes were in place to assist in identifying patients who may need extra support. This included alerts on patients records to show what support they needed with communication such as interpreters. The practice was responsive to the needs of older patients and offered home visits and urgent appointments for those with enhanced needs and complex medical issues.

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.

The practice engaged in regular, well attended multi-disciplinary team meetings to assess and support patients in reaching decisions about their end-of-life care. This identified that patients’ views had been sought and respected.

We were assured that safeguards were in place to ensure decisions were made in the person’s best interest.