70 Norwood Road

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 in October 2023, we rated this key question as requires improvement. At this assessment, the rating has changed from requires improvement to good because we found no issues with person-centred care, equality, diversity and inclusion.

This service scored 68 (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 care plans 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. There were alerts on patient records to identify patients that may require additional support during appointments or any need that may be flagged by the system. There were named champions to support each group of patients such as carers’ champion, dementia champion among others.

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, for example, diabetes remained prevalent within the patient population and the practice ensured care was tailored to meet the needs of the affected patients by promoting external education in small patient groups to ensure patients understand their health conditions and how to maintain their health safely. Each specific patient need was identified, assessed, monitored and reviewed from our check of the various care plans. The care plans included those of patients identified to be living with learning disability, mental health conditions, and dementia. The practice had various adaptions for different patient groups such as domestic abuse, homeless, and carers. The practice was accredited to be veteran friendly and patients who are homeless could receive care without any discrimination.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. Information on health services available at the location was available in a range of languages including other health awareness posters such as sepsis and complaints procedures. The practice had access to interpreter services. Information provided by the service met the Accessible Information Standard. Patients were informed as to how to access their care records. Staff at the service were multi-lingual which helped with communication and information sharing with the patient population. There was a hearing loop in place for use for any patient who may require it. The practice staff educated the patient population on how to access the services provided using the NHS App through the drop-in sessions in collaboration with the Primary care network (PCN).

Patients were informed through the patient information boards and TV screen at the waiting area of the practice which included information on support available for carers and various vaccinations available (flu, meningitis, pneumococcal and childhood immunisations). Other information included availability of chaperones, diabetic eye screening, patient participation group information and Park run (an initiative to encourage patients and staff to participate in running). There was also information to encourage patients to attend the blood pressure and diabetic monitoring for the local population at the community centre.

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. Learning from complaints was evident and staff were able to identify changes made because of patient feedback, including complaints. At the last assessment in October 2023, the practice failed to ensure all complaints were recorded including those made verbally. During this assessment, we found that all complaints were recorded, investigated and responded to in a timely manner and learning shared with the staff to embed into daily practice which indicated that the practice had improved since the last assessment.

The service recognised it needed to improve patients' experience of contacting the service. They had taken steps to improve patient experience in this area. However, there was insufficient data so far to show that this had had the necessary impact. At the last assessment in October 2023, there were concerns with how patients could access the practice from the National GP Patient survey data available at that time. At this assessment, the concern remained the same. For example, patients did not find it easy to contact the practice using the phone, website or NHS App. In 2025, the service scored below average in the National GP Patient survey question about patients overall experience of contacting the GP practice (45%) compared to the local (71%) and national (70%) averages.

The percentage of respondents who found it easy to contact the practice by phone was 42% compared to the local (60%) and national (53%) averages. The percentage of respondents who found it easy to contact this GP Practice using their website was 49% compared to the local (52%) and national (51%) averages. The percentage of respondents who found it easy to contact the practice using the NHS App was 39% compared to the local (51%) and national (49%) averages.

The service completed a telephone audit on patient access in response to the assessment findings in October 2023 which identified areas where improvements were needed such as many calls were left unanswered after waiting for too long on the phone. As a result of the audit, the practice took action to ensure calls were answered within 1 minute and within a maximum of 10 minutes. The practice continued to liaise with the patients and relevant organisations to improve access. During the site visit, the leaders and staff told us that ensuring the right clinician was seen by the patients at the right time remained a priority. For patients who were not digitally literate enough to use the online appointment booking system, the staff encouraged them to come to the practice where they were offered support. The practice also referred patients to the pharmacy first services where appropriate.

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. The service 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. The practice ensured signposting to relevant support services was done where appropriate including social prescribers and obtained the right information from the patients at the point of registration.

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 in spite of their circumstances. 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. However, we found 3 patients who had Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) records set up during care in hospital. However, they had not been reviewed with the patient after they got back home from the hospital to ensure the decision was current and valid to ensure the right information was recorded and documented. We saw from the records that the identified patients had been visited by community services team and primary care network (PCN) paramedics following referrals from the practice after discharge from the hospital. During the site visit, the leaders told us that the DNACPR records would be reviewed and the right information will be ensured was recorded for each patient for future reference for patient safety.

We saw care plans for patients on palliative care and these were correctly recorded and documented. They were personalised to the patients and a named clinician always made a call to the family in the event of a bereavement.