The Randolph 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 inspection, we rated this key question as good, at this inspection, the rating has changed to requires improvement, as we found issues with equality of access, National GP patient survey results were below local and national averages and, though the practice were aware and had taken action, there was no evidence yet that this had improved the patient experience. Patients told us they were not always able to access appointments and treatment in a timely way

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received a variety of mixed feedback from patients regarding receiving care tailored to their needs and centred around them as the patient. Patients' who did not feel the practice provided person centred care told us, they had difficulty accessing face to face appointments with the GP via the practice’s app or via telephone. Some patients (21) told us they had difficulty accessing the practice by phone or using the app, patients told us the app was not always functional, call back facility did not always work and waiting times on the phone lines were long. The practice provided data that showed more than one in eight calls is abandoned and, of those not abandoned, the average time in the queue is over 8 minutes. We saw from the results of the National GP Patient Survey (2025) that 81% of patients said their needs were met. This was below the national average (90%). The practice provided evidence to demonstrate an action plan was in place to address these results, but the results of the 2024 results were slightly higher in comparison to the 2025 results and so the impact of this is yet to be seen.

Whilst we saw negative feedback, we also found other patients were happy and felt staff went above and beyond to assist with their queries and the doctors took their time to explain everything. However, evidence from patient feedback showed the importance of flexibility and informed choice of care was not always reflected in the services provided. The results of the National GP patient survey 2025 found that 81% of patients said they were involved as much as they wanted to be in decisions about their care and treatment. This was below the national average (91%) and local average (90%).

The practice worked in partnership with other services to meet the needs of the patient population. 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.

We saw evidence of established links with services in the community including the multidisciplinary team, local authority and voluntary organisations for vulnerable patients. However, continuity of care was not always reflected in the services provided as patients requiring an assessment from the GPs were not always able to do so in a timely way and ended up using hospital services as highlighted in patient feedback.

The practice supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs, for example information to promote the take up of screening and immunisation programmes was available in a range of languages. Information and resources were available for patients to support them to understand how to access services. The practice made reasonable adjustments for disabled people. Interpreting and translation for people who did not speak English as a first language and for people who used British Sign Language were available.

We found patient information was kept secure and how the practice complied with the Accessible Information Standard and that information about people that was collected and shared was in line with data protection legislation requirements. We saw the practice shared minutes of meetings from their PPG on the practice website, and these were also available on the noticeboard in the reception area.

Patient experience of the service as indicated in the National GP Patient Survey, showed that 66% of patients felt the healthcare professional was good at listening to the patient. This was lower than the local (85%) and national (87%) averages.

We saw information on how to make a complaint was displayed in the waiting area and on the website. We reviewed 4 complaints received since January 2024 via their complaints log. 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 leaders wanted to make the complaints process more streamlined, so they introduced a weekly meet the managers clinic to address, respond and investigate issues in a timely manner.

The service did not always make sure that people could access the care, support and treatment they needed when they needed it. A range of appointments were offered, but people were not always able to access care and treatment in a timely manner. Information from complaints showed delays had led to people accessing other services as they were unable to get an appointment within a reasonable time frame to meet their needs. This was reflected in the National GP patient survey results which showed the practice was significantly below the national and local averages for responses about access to the practice. This was also echoed by the patients we spoke to on the day and the PPG members who expressed issues with obtaining appointments through the app, telephone and online. The results showed 46% of the respondents had a good overall experience of contacting the practice (national 70% and local 71%), 30% found it easy to contact the practice on the phone (national 53% and local 60%), 23% found it easy to contact the practice using the website (national 51% and local 52%), and 74% found the reception and administrative staff helpful (national 83% and local 82%). Feedback from 6 patients received directly to CQC saw that they received treatment from alternative services due to not being able to obtain appointments at the practice. For example 1 patient informed us they had a telephone consultation that they felt was unhelpful and so decided to attend accident and emergency where they were later admitted for 3 days, another patient needed to go hospital as they had run out of medicine despite informing the practice beforehand. Feedback from patients was that appointment booking in advance was limited, with one patient saying she opted to go to the hospital for her blood test, as same day appointment system did not suit her as a working patient.

In response to the National GP Patient Survey data and from feedback from members of the community, the provider had identified changes to improve access to the service. Leaders understood the challenges to patient access and services were being designed to make them accessible and timely for people who were most likely to have difficulty accessing care. For example, they offered extended appointments for vulnerable people. The practice had put in place a call back facility to reduce people’s waiting time on the telephone and to improve access. There was a designated member of the team to assist digitally disadvantaged patients, and the practice employed more staff across the different staff groups. The practice told us they obtained feedback from various sources such as the GP patient survey, FFT, complaints and informal feedback from patients. The practice shared the action plan to improve patient experience.

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. Staff told us they respected and appreciated people’s backgrounds and cultural values and received training in equality and diversity. Patients were informed that chaperones were available. A chaperone is an impartial observer present during an examination or consultation when a patient may feel vulnerable, for example during an intimate examination. Staff who acted as a chaperones had completed the relevant training.

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. 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. 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. Leaders understood the requirements of legislation when considering consent and decision making and staff had access to policies to support them.

The practice did not look after any care homes but people who may be approaching the end of their life were identified. The practice demonstrated patient involvement in their care and treatment, in DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) decisions. There were registers held for those patients who were vulnerable, who were on the palliative care register, or 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.