Holmcroft 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

This is the first inspection for this service since its registration with CQC. The service ensured people were supported to plan for important life changes and made sure they worked in partnership with people in order to respond to changes in people’s needs. Leaders understood the needs of the local population and worked in partnership with other services. Information was provided by the service in various formats, adhering to the Accessible Information Standard (AIS). Processes were in place to ensure people could register at the practice, including those in vulnerable circumstances.

Indicators from the latest GP national patient survey for access to appointments were below local and national averages. This highlighted concerns in the quality statements for listening to and involving people, equity in access and equity in experiences and outcomes. For example, the National GP Survey 2024 results showed that 29% of patients found it easy to get through to this GP practice by phone when compared to the local average of 52% and the national average of 50%. The practice’s own internal patient survey results for 2024 found 22% of 116 patients found it easy to get through by phone. The service were aware of these concerns and in response had set up a working group with patients who had utilised social media to state their dissatisfaction with aspects of the service provided such as access. In collaboration they had worked to resolve the issues raised, formulated an action plan and monitored progress with these groups. This key question has been rated as good.

This service scored 64 (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.

Leaders told us that in response to patient feedback, they had reviewed their care model and reviewed the clinical skill mix. Normal opening times were Monday to Friday between 8am to 6.30pm. The practice closed between 1pm and 2pm every Tuesday for team training. The on-call doctor was available during this time for emergencies. There were pre-bookable appointments on a Tuesday evening for patients who would otherwise find it difficult to see a doctor during normal opening hours due to their work. From our review of clinical records, we did not identify any issues relating to patients not being supported to understand their condition and being involved in decisions about their care.

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.

Leaders had a good understanding of the local population and complied with the accessible information standards within the practice. Staff had received training in diversity and inclusion. 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, building relationships with community groups to promote the take up of screening programmes. There were established mechanisms for engaging with the community healthcare provider.

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

Information to promote the take up of screening and immunisation programmes was available in a range of languages. The practice had access to interpreter services, including British Sign Language (BSL). Information provided by the service met the Accessible Information Standard (AIS). Patients were informed as to how to access their care records. Appointments included a mixture of telephone, face-to-face and home visits which were noted on the practice website. Staff confirmed they had completed information governance training which included General Data Protection Regulation (GDPR).

The service did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment, and support.

Patient feedback from the national GP patient survey 2024 data was significantly lower than local and national averages. For example, the percentage of patients who said the healthcare professional they saw or spoke to was good at listening to them during their last general practice appointment was 78% when compared to the local and national averages of 87%. Patients’ overall good experience of this GP practice was 51% when compared to local average of 76% and the national average of 74%. Their in-house patient questionnaire dated, 2024/2025, found that 85% of patient respondents reported a ‘good’ to ‘excellent’ level of satisfaction on the doctor/nurse's ability to listen. Leaders told us they were aware of patient feedback from the national GP patient survey data, from online reviews and from complaints received into the practice. Action plans were devised from findings in the National GP Survey, their internal surveys, feedback from the Friends and Family Test, those who had attended for an appointment, as well as engaging with patients via their PPG and working group. 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 service did not always make sure that people could access the care, support, and treatment they needed when they needed it.

In response to the National GP Patient Survey 2024 data and from feedback from members of the community, the provider had identified changes to improve access to the service. Patients had raised numerous complaints on public websites, with stakeholders and a few directly to the Care Quality Commission. The online appointment system had not always been well received by patient groups. The service had subsequently engaged with local groups and co-produced action plans to assist patients to engage with the digital changes to appointments they had introduced. Patients could make an appointment at the reception desk by being supported by staff to complete the digital process. Staff supported patients to do this over the phone, and those who were able, they completed the digital forms electronically. Leaders showed us that the changes to the telephony system enabled clear sight of the number of incoming calls, the time waiting if any, and the length of the calls. This enabled management oversight and the ability to request staff switch from administrative roles to support incoming calls when needed. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. For example, we saw that an appointment slot was held towards the end of each working weekday for veterans. If this was not required, it would be utilised for urgent appointments or those who preferred a quieter appointment time, such as people with a learning disability. The practice had implemented changes for improvement. These changes needed time to be embedded to ensure improvement in patient satisfaction.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this. Feedback from people into Care Quality Commission, NHS website, practice complaints and from the national GP patient survey results showed patients dissatisfaction with getting an appointment or getting through to the practice by telephone. A Member of Parliament had also become involved following patient feedback. The national GP survey results show that 29% of patients found it easy to get through to the practice via phone, compared to the local result of 52% and the national result of 50%. 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 adjusted 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 and Travellers. The practice is also an accredited Veterans practice and A Safe Surgery.A Safe Surgery can be any GP practice which commits to taking steps to tackle the barriers faced by many migrants in accessing healthcare. 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.

The records we reviewed 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. Clinicians we spoke with demonstrated a clear understanding of the requirements of legislation and guidance when considering consent and decision making relating to end-of-life care. Staff told us they regularly attended multidisciplinary team (MDT) meetings, where they discussed patients who received end-of-life care.