Southway 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 assessed all quality statements in the responsive key question. At our last assessment we rated this key question as requires improvement. This was due to learning from safety events not effectively being shared with staff, minutes discussing safeguarding concerns was lacking relevant information and complaints logs were lacking information and actions.

At this assessment we rated the key question as good. We found evidence that the practice met people’s needs and that staff treated people equally and without discrimination. People were involved in decisions about their care. The practice provided information in a format people could understand. People knew how to give feedback and could be confident the practice took it seriously and would act on it. People received fair and equal care and treatment. The practice worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood the options if they chose to decline care and treatment.

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 practice made sure people were at the centre of their care and treatment choices. Care plans reflected the physical, mental, emotional, and social needs of patients. This included those related to protected characteristics under the Equality Act 2010. For example, people’s care records indicated if they had a vision impairment. This indicated to staff reviewing their appointment request they may require additional support to attend. The practice told us they offered reasonable adjustments and took individual preferences into consideration. For example, offering access to interpreter services and information available in a variety of formats. For example, braille, large print or provided in an alternative language. This helped patients understand their care, treatment and conditions.

Staff considered they got to know people’s needs during appointments and they responded appropriately. Our review of clinical records showed patients were supported to understand their condition and were involved in planning to meet their care needs. The practice worked in partnership with people to respond to any relevant changes in their needs.

The practice understood the diverse health and care needs of people and their local communities. Care was joined-up, flexible and supported choice and continuity. 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. For example, building relationships with community groups to promote the take up of screening programmes. There were established links with the community healthcare provider such as with district nurses which enabled joined up care provision.

The practice held a register of patients living in vulnerable circumstances including those with learning disabilities. The practice checked that referrals to external services received were actioned.

The practice had a nominated safeguarding lead. Safeguarding concerns were regularly discussed as they were integrated into their monthly clinical governance meetings. Relevant staff attended or had the minutes shared with them and when needed action was taken. Meeting minutes confirmed this.

The practice had access to their Primary Care Network (PCN) for additional support. A PCN is a group of GP practices working closely together, aligned to other health and social care staff and organisations, providing integrated services to their local population. People told us they do not always receive continuity of care from the same clinician. However, the provider told us this could be requested by a patient. Training records showed staff were given additional training to provide support for those with additional support needs. For example, dementia and learning disabilities.

The practice supplied appropriate up-to-date information in formats that were tailored to individual needs. Interpretation services could be accessed to support people who did not have English as a first language. Information provided by the practice met Accessible Information Standard requirements. Patients were informed how to access their care records.

The practice supported people and their carers when needed to find further information; and to access community and advocacy services. The practice website contained information to support and educate people, this included a Heath A-Z and a Live Well section, which covered areas such as childhood vaccines mental health and contraception support and guidance.

The practice had clear systems to enable people to provide feedback and ideas or raise concerns about their care and treatment. Complaints were managed in line with the practice’s policy. There was a system to log complaints, audit action taken and monitor for themes and trends. We found investigations were carried out and feedback was shared with relevant people. People who use the practice offered CQC their feedback saying they have found the staff to be professional, empathetic and felt listened to. The practice used NHS Friends and Family Test (FFT) and suggestion boxes which allowed them to collect feedback from their patients. FFT is a national initiative and is a quick and anonymous way for patients to provide feedback on the care or treatment they receive from NHS services. This was collated and recorded by the provider with responses and actions being captured. An example was to remind all staff to ensure doors are closed before starting a consultation. We observed this being complied with.

The practice made sure that people could access the care, support and treatment they needed when they needed it. In response to the National GP Patient Survey data the provider had identified changes required to improve access to the practice. For example, reception staff completed triage forms for patients who are unable to access the online form.

Over the last 12 months we received 22 give feedback on care forms about the practice. Five of which were related to when people found it difficult to access appointments online or over the phone. Eleven forms contained positive feedback. For example, excellent service from all staff and finds the appointment system accessible. People were able to request an appointment with a specific clinician and this was usually at a time most suitable for them. The practice was open from 8am to 6pm on weekdays. A range of appointment types were available, which included telephone and face to face. Home visits and urgent appointments were available for patients where appropriate. We reviewed the practice appointment system and found the next available routine GP appointment was available in 1 week after our site visit and urgent appointments were available on the day of the site visit.

Care and treatment were tailored, when possible, to meet the needs of people who were most likely to experience inequality in experience or outcomes. Leaders proactively sought ways to address any barriers to improving people’s access. This included an online triage form to support the demand for appointments which ensured appointments were available to those who needed them. Staff explained and demonstrated how they provided an inclusive approach to care. Adjustments were made when needed to promote equity in people’s experience and outcomes. Staff used appropriate systems to capture and review feedback from people using the practice. For example, due to some of the feedback provided through NHS Friends and Family Test (FFT) test the practice are reviewing their online triage form to ensure it is accessible to all patients. FFT is a national initiative and is a quick and anonymous way for patients to provide feedback on the care or treatment they receive from NHS services.

People were supported to plan for important life changes. They were given 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 decisions and this was documented. This information was shared with other services when necessary. We reviewed 5 patient records where there was a do not attempt cardiopulmonary resuscitation decision documented in their care record. All 5 patient records documented that a capacity assessment had been carried out, to ensure the patient was able to make the decision independently or with the support of relevant people.