The Limes 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

At the last assessment we found that the practice did not always organise and deliver services to meet patients’ needs, patients could not always access appointments in a timely way and complaints were not used to drive continuous improvement. At this assessment we found no improvements had been made. Patients continued to face difficulties in accessing appointments, the complaints process required strengthening to ensure there was an effective system in place to ensure all people received a timely response.

Patient feedback continued to highlight difficulties in accessing services. The practice had a duty doctor available to provide advice and to deal with urgent requests, but staff reported a shortage of appointments impacted on availability.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Negative feedback had been received through whistle blowing comments to the CQC and online feedback concerning the care provided to people, access and being able to speak or see a clinician to discuss health needs.

Results of the National GP Patient Survey demonstrated 90% of people said they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment, this was in line with local and national average of 91%.

We found during the clinical review of people's records that improvements had been made to ensure people were aware of their health conditions and the appropriate care and treatment was provided to assist them in managing their health conditions.

We were unable to gain assurances that staff had been trained in equality and diversity, safeguarding and mental capacity. The practice had implemented a patient participation group recently and were currently trying to recruit people to join the group. The practice was using the Friends and Family Test (FFT) to gather patient feedback on their experiences of the practice. Results from March 2025 showed the practice had received 172 responses and 83% of people had rated the practice as good or very good.

We found that continuity of care was impacted due to the lack of systems in place to ensure documentation from out of hours providers was actioned and people’s records were updated with the information.

We saw the practice worked in partnership with other services to meet the needs of its patient population. Evidence provided showed there were safeguarding and palliative care meetings in place with local community teams to ensure continuity of care.

The practice told us they attended primary care network meetings and we were provided with minutes of meetings of the primary care network to demonstrate some of the leadership's team participation.

The practice held registers of patients living in vulnerable circumstances including those with a learning disability, mental health or safeguarding concern. Alerts were added to clinical records to ensure staff were aware of patients who may need extra support.

The practice website was accessible to patients. The 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, however due to the diversity of the local population there was no facilities to change the language of the website to provide information to people who did not have English as a first language.

We found the summarising of clinical records had not been continued since the person doing this role had left in December 2024. Information from NHS111 and other emergency services was also not been actioned due to staff shortages. Staff told us that there were no staff trained in this area. The leadership team were aware of the backlog, but we were not assured that any action had been taken to address this.

There were limited systems in place to support people who faced communication barriers to access treatment. A hearing loop was in place to help people who had hearing difficulties, however none of the staff we spoke with were aware of how to use it. People who required interpreters were advised to bring a family member or directed to a local interpreter. No checks had been made by the practice on the interpreter to ensure they complied with confidentiality standards.

 

We found there was a system for recording complaints, however the system was not effective in ensuring all complaints were dealt with in a timely manner. At the time of the onsite visit, we were told there were 20 outstanding complaints. From the evidence we reviewed, there was no process in place to confirm people received a satisfactory response and the actions the practice had taken to mitigate future risk and improve the outcomes for people that use the service. Minutes of staff meetings we reviewed showed complaints were discussed and actions were also listed on the minutes. However, on speaking with the management team we were told that learning was not shared with the whole team, therefore we were unable to gain assurances that there was a system in place for learning with the whole team.

The practice had a complaints policy in place; however, we found the systems to monitor complaints and use patient comments to improve the quality of care was not embedded to ensure improvements were demonstrated. Information on how to make a complaint was available on the practice website, we were unable to see if there was any information about how to complain within the practice waiting room due to the noticeboards being in disorganised.
 

The practice had a duty doctor available to provide urgent on the day appointments if required, however feedback received at the CQC and through NHS UK and Google reviews, showed people had difficulties in obtaining an appointment. The National GP Patient Survey data was below local and national averages. We found that patient feedback regarding access to care and treatment was significantly lower than national averages for how easy it was to get through to someone at their GP practice on the phone. For example: 39% found it easy to get through on the phone.

Patients could access appointments by phone, online and by visiting the practice. The practice website provided information for patients regarding how to book an appointment, however 17% of patients found it easy to access the practice by website.

Leaders demonstrated they were aware of the challenges to patient access and had implemented a new telephone system. However, we found that this improvement had not been sufficient as the culture of the practice continued to impact on appointment availability. At the last assessment we were told that some of the GPs worked in silos which caused difficulties for staff trying to book appointments. At this assessment we found this continued and some GPs still refused to see patients that were not specifically registered under their name. Staff reported that GPs still refused to see other clinician’s patients or action tasks or prescription requests, this was also highlighted by clinical staff who said they could not approach some of the senior clinicians due to their lack of support. In addition, we found GPs continued to refuse to do home visits which impacted on patients being seen in a timely way.

We found some of the GPs and other clinical staff had left in the last 6 months which had impacted on appointment availability. A new advanced nurse practitioner was now in post and locum doctors were being used to provide appointment availability.

Appointments with a GP were available throughout the week. When the practice was closed people were able to contact 111. The practice offered appointments from a variety of additional clinical staff for example nurses, health care assistant and pharmacist. Extended access was available on a Monday from 6.30pm to 8pm and at other local GP practices throughout the week and Saturday morning through the primary care network.

The practice had arrangements in place for prioritising patients, however due to feedback we were not assured this was managed safely and effectively.
 

The practice had implemented the Friends and Family test (FFT) which indicated that in January 2025 79% of feedback rated the practice as good or very good. This had improved with the March 2025 results with a score of 83%.

The provider hadn't 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. We saw examples where the practice had tried to meet the needs of vulnerable patient groups and removed barriers for improved patient experience. For example, the practice premises had a hearing loop in place, however staff were unaware of how to use it. We also spoke with some of the management team and they were also unaware of how to use the loop to support patients with hearing difficulties. The practice had access to the language line but we were informed by the management team that people were encouraged to bring family members to interpret as the language line was expensive to use. We found people with learning disabilities experienced additional care through annual reviews. People with dementia were referred to appropriate services where required.

The practice had an active PPG, which met with key staff members at the practice, quarterly. Improvements were discussed as part of the meeting. For example: One of the areas was how to advertise the surgery better. The action was to set up a business Facebook page. We found a Facebook page was in place, however no information had been added since December 2024.

 

There were registers held for those people 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.

We were told that the practice held multidisciplinary meetings with other agencies to share and discuss information relating to care and treatment, for example, those on the practice palliative care register. 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.