Eldene Surgery Also known as Dr Philip Gnana Asirvatham Bauliah

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 the service met people’s needs, and staff treated people equally and without discrimination.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

This service scored 82 (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 2010. Our review of clinical records showed people were supported to understand their condition and were involved in planning for their care needs. People were also involved in decisions about their care. The service held regular multi-disciplinary meetings with other professionals to plan and coordinate care, supporting holistic and person-centred outcomes.

People were able to seek support from a clinician of their choice, although this could sometimes result in a short wait for an appointment. Staff demonstrated a person-centred approach to their work, and during our onsite visit we observed staff being supportive and compassionate towards people. The service had access to a health and wellbeing coach and social prescriber, who supported people through a holistic approach tailored to their individual needs.

The service made reasonable adjustments to support communication, offering interpreter and translation services, as well as a hearing loop in reception. A private room was available for those needing privacy or a quiet space to discuss personal concerns. The service also made reasonable adjustments for people who found it difficult to access services, including offering home visits from GPs, paramedics, nursing staff and healthcare assistants.

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.

The service worked in partnership with other services to meet the needs of its population. The service had tailored its provision to meet the diverse needs of its community. This included building relationships with community groups to promote the uptake of screening programmes and offering cervical screening to people who were housebound.

The service maintained a close working relationship with the local hospice team to deliver coordinated end-of-life care under the Gold Standards Framework. At the time of our inspection, all people on the palliative care register had received an annual review and had a care plan in place. The service recognised the challenges of its transient population and took proactive steps to encourage engagement with healthcare services.

Nurses held specialist roles, for example in diabetes and asthma management, enabling them to carry out targeted annual reviews and provide consistent, coordinated care. The service benefited from a consistent clinical team, which reduced the need for locum staff and supported continuity of care for people who used the service.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Information provided by the service met the Accessible Information Standard. Leaflets were readily available in the reception area, and posters were displayed to inform people about the service and the various services available to them. People were also provided with clear information on how to access their medical records.

Information to promote the uptake of screening and immunisation programmes was available in a range of languages upon request. Interpreter services were available for people who did not speak English as their first language, and this information was clearly recorded on individual care records. People who used the service could select their preferred language on reception check-in screens, which promoted accessibility, inclusivity, and privacy, enhancing overall experience.

In accordance with the Equality Act 2010, the service provided reasonable adjustments to promote accessibility. This included a portable hearing loop for people with hearing impairments and a range of communication formats, including large print and easy-read materials, to ensure information was accessible to all.

To promote accessibility and inclusion, the service maintained a user-friendly website with a language translation feature. The site offered information on health conditions, local community resources, and other healthcare providers, including dental and eye care services, supporting people to make informed care choices.

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.

Complaints were managed in line with the service’s policy. The service ensured people received an apology when necessary and were guided to the Parliamentary and Health Service Ombudsman if they wished to escalate their concerns further. Accessible information was available at the service and online, enabling people to share feedback about their experiences and understand the process for raising concerns or complaints. Learning from complaints was evident and staff were able to identify changes made as a result of service user feedback, including complaints. For example, feedback from people who used the service highlighted a desire for an online appointment system and extended access. These services were already available and promoted on the provider’s website. An internal survey showed approximately 58% of respondents did not use the website for information about the service. In response, the provider increased promotion of these services through posters displayed in the waiting areas.

The service also actively used feedback from this survey to improve access and responsiveness. The 2025 survey identified delays in booking routine appointments as an area for improvement. In response, leaders reduced the 28-day and 21-day appointment embargoes (a temporary block on an appointment slot, preventing it from being booked until the specified time) to 7 and 3 days, opening more routine appointments. Following this change, people who used the service reported more timely access to appointments.

Themes and trends from concerns and complaints were collated and discussed at regular clinical and business meetings. Minutes from these meetings were circulated to staff to ensure they were informed and that any learning was acted upon.

Leaders told us feedback from people using the service was routinely gathered through the NHS Friends and Family Test. This information was reviewed and used to drive improvements and was shared with both staff and people who used the service. Staff reported they were encouraged to share ideas and feedback, and these were taken seriously and addressed. For example, staff indicated that locating available clinician or blood test appointments for people who used the service was a time-consuming process. Consequently, the service implemented a dedicated button within the clinical system to streamline the identification of available appointments.

The service had an active patient participation group (PPG), with its aims set out in a term of reference. The group, made up of people registered with the service, acted as representatives of patients’ views. A PPG representative told us they felt included in discussions and that their feedback was listened to by service leaders. People felt supported to raise concerns or feedback and felt staff treated them with compassion and understanding when they did so. Representatives from the PPG felt the provider took concerns seriously and proactively made improvements to the service. They explained that feedback raised through the PPG was carefully reviewed, discussed, and acted upon by the service where needed. Outcomes were communicated to people and shared with the PPG to ensure members knew their input was valued and led to change. For example, the PPG highlighted concerns regarding the closure of the Prescription Ordering Direct service for people unable to access online services. In response, the provider formed a new team to manage requests and developed an internal online prescription ordering process, making it easier for people to submit repeat prescriptions and streamlining the entire process.

The service was exceptional at ensuring people could access the care, support and treatment they needed when they needed it. The premises were wheelchair accessible, with all clinical rooms located on the ground floor. An automatic door had been installed at the entrance to support ease of access.

People could access the service to suit their needs, for example online, in person and by telephone. In response to the 2024 National GP Patient Survey data and from feedback from members of the community the provider had identified changes to improve access to the service. For example, the service had introduced a new phone system with features such as increased call capacity and call queuing. This system enabled leaders to monitor call wait times and the number of calls waiting, supporting the appropriate allocation of staff and resources. The service also promoted the use of their online services through posters and text message links, to enhance digital access. The 2025 National GP Patient Survey reported improved access: 65% of respondents found it easy to contact services by phone, 55% via the website (up from 35% in 2024), and 66% via the NHS App (up from 19%). All of these results were significantly above both local and national averages.

During our site visit, we examined the telephone data from 8am to 4pm, with the average call wait time being 1 minute and 48 seconds. Leaders monitored call activity throughout the day using both a display board in the call room and the manager’s computer, enabling prompt action when queues begin to build. During periods of high demand or reduced capacity, additional staff provided support on the phones and calls could be diverted to their linked services within the primary care network (PCN) to maintain access and minimise delays. Performance data was also reviewed in weekly meetings, where trends were analysed, learning was shared, and improvement actions were agreed to enhance call handling and reduce waiting times. Representatives from the patient participation group (PPG), and people we spoke to on the day of the inspection, informed us they were able to get through to the service quickly and get appointments promptly, especially if it was urgent. This was further evidenced by feedback collected through the NHS Friends and Family Test for the service.

Leaders demonstrated an evidence-based approach to improving access and reducing missed appointments. Routine audits of ‘did not attend’ (DNA) rates identified 591 missed appointments between October and December 2024. Results were discussed with the PPG who played an active role in developing solutions. Following another audit which showed 200 people had three or more DNAs, the service introduced a structured communication strategy. Alongside standard text message reminders, the service introduced a protocol whereby individuals receive a text notification on the day of any missed appointment. Additionally, follow-up letters are sent after each of the first three missed appointments within a six-month timeframe. On the fourth occurrence, people may be removed from the list unless they are receiving ongoing treatment or are pregnant. A re-audit for January to March 2025 showed a reduction to 494 missed appointments. Working with the PPG, the service planned to continue regular audits and assess further initiatives to improve attendance and engagement, ensuring appointment capacity was used effectively and access for other people who used the service was improved.

The service had reviewed and improved its systems for arranging home visits. A dedicated member of staff had been appointed to focus on providing care and treatment to people in their own homes. Nursing staff also supported in providing care and treatment for people who were housebound, including immunisations, long-term condition reviews, and cervical screening.

The service supported people to access care more easily through a range of options. People were able to secure appointments outside of standard operating hours, such as Saturday clinics, due to enhanced access arrangements with the local GP federation. Additionally, an online consultation option was available, offering video appointments from 8am to 10pm on weekdays and 8am to 4pm at weekends. This approach delivered increased flexibility, ensuring individuals, including those working typical office hours, could access healthcare in a manner that suited their schedules.

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. The service’s immunisation programme aimed to reduce health inequalities by ensuring immunisations were accessible to all individuals. A particular focus was placed on transient populations, helping to ensure people who might otherwise face barriers to care were able to receive recommended immunisations.

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 service, 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. As a result, the service offered multiple ways for people to book appointments and order prescriptions, ensuring care was accessible to all. This approach particularly supported elderly people and people experiencing homelessness, who may face barriers to using digital technology, helping to ensure these groups could access the care and treatment they needed.

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 remote clinical searches 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, including via integrated care records. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were made in line with relevant legislation, were appropriate and recorded clearly.

The service collaborated with the community hospice team at Prospect Hospice to ensure effective palliative care. All people receiving end-of-life care were reviewed during regular clinical meetings, promoting coordinated, person-focused support. There were strong support and wellbeing arrangements in place for staff when impacted by the death of people they cared for.