Enderley Road 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

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination.

At our last inspection in 2018, we rated this key question as Good. At this assessment, the rating remains the same.

This service scored 71 (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.

Patient feedback we reviewed was positive. Patients were complimentary about their encounters with clinical staff and described them as professional, caring and understanding. Non-clinical staff were described as helpful.

Appointment triage was undertaken by the GP partners, which supported continuity of 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.
Social Prescribers were involved in communicating with patients to help them navigate the health and social care system and to keep them informed about practice initiatives, including publicising the Patient Participation Group (PPG) and promoting the Friendship Café.
We saw the practice worked in partnership with other services to meet the needs of its patient population. This included attending scheduled meetings with practice managers, the primary care network (PCN), integrated care board (ICB), and multidisciplinary teams.
The practice 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. There were established mechanisms for engaging with the community healthcare provider. These meetings supported collaboration, coordinated care, and the effective delivery of services.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.
People could access the service to suit their needs for example online, in person and by telephone. The practice utilised PATCHS, an online consultation service that facilitated communication with the GP and supported translation into multiple languages, allowing people to submit requests in their preferred language. Staff were trained to assist patients with completing PATCHS forms and to provide support at the kiosk in the waiting area.
The practice website included accessibility features, such as large font options and language selection, to support patients with different needs.
Information to promote the take up of screening and immunisation programmes was available in a range of languages. 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.

The practice implemented several improvements, including adding a ground floor consultation room to improve access for disabled patients following feedback. A duty clinician was introduced to support care navigators and increase same-day capacity for vulnerable patients, alongside a reviewed triage and risk-rating system to ensure appropriate booking by priority.

The practice received recognition from the Integrated Care Board (ICB) for achieving a high survey response rate of 23.85%, with 76.80% of respondents reporting a positive overall experience in the 2025 National GP Patient Survey.
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 took steps to ensure people could access the care, support, and treatment they needed when required, however, the impact of these actions was not yet reflected in patient feedback.
Results from the National GP Patient Survey (2025) showed the practice scored below the national average on indicators relating to access to the practice. For example, 45% of respondents found it easy to contact the practice by phone (national average 53%), and 58% of respondents responded positively to the overall experience of contacting the practice (national average 70%).
Improving access remained a priority and ongoing focus for the service. The practice regularly reviewed feedback from both internal and external patient surveys, monitoring results over time to identify trends and areas for improvement. The practice had been responsive to this feedback and had worked in partnership with the Patient Participation Group (PPG) to support and implement improvements to patient access. For example, there were changes to staffing, systems and processes, reception workforce stability, website improvements, workflow enhancements, routine appointment bookings, and NHS App promotion with support from the PPG. They aimed to improve patient experience in access by at least 10% over the next year.

People could access the service to suit their needs for example online, in person and by telephone. The practice offered extended appointments for patients with a learning disability, those needing translation services, and for patients presenting with multiple concerns. Treatment rooms were available on the ground floor, with a ramp and automatic door at the main entrance. An additional side ramp provided access to treatment rooms that were not internally step-free.
The practice offered appointments through extended access hub services to support patients, particularly working individuals, outside of normal working hours.
The practice worked closely with external services to support vulnerable groups, including patients experiencing domestic abuse, housebound patients, young migrants, military veterans, carers and homeless patients. Residents in nursing homes and patients with complex needs received coordinated care from named GPs with regular reviews

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. For example, a mental health charity held clinics at the practice to support patients with mental health care. Patient feedback indicated that the clinics were helpful in supporting their mental health needs. These clinics were in addition to a mental health link worker and social prescriber who provided support to patients as part of the PCN.
The practice served a diverse population with pockets of deprivation and recognised potential inequalities in access to care. The three most common languages (Arabic, Gujarati and Romanian) were identified, and signage and patient information were made available in these languages to improve accessibility.

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. 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.
Staff were trained to provide care for patients with learning disabilities and autism, with 92% of annual health checks for patients with a learning disability completed at the time of assessment. The practice offered urgent appointments and home visits for vulnerable patients and those with complex care needs.

The practice worked with the Patient Participation Group and local charities to run a health fair for the local population, supporting social cohesion and improving patients’ access to health and social care organisations.
The practice provided care to the majority of residents in a local care home. The care home reported that the practice provided weekly GP visits and medication reviews, with blood tests being undertaken by care home staff at the request of the GPs. They described the practice as accessible, with clinical and administrative staff who were responsive, helpful, and reassuring. GPs were praised as caring, professional, and attentive, involving multidisciplinary teams when needed. No complaints had been received, and the care home highlighted a positive, collaborative relationship with the practice.
 

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 worked closely with system partners, including the community frailty service, through regular meetings to coordinate patient care. The provider had received positive feedback from the frailty team, with practice staff described as highly responsive, cooperative, and efficient.