Drs Leung, Mallick, Sherrell & Hobbs

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

Responsive – this means we looked for evidence that the service met people’s needs. At our last assessment, we rated this key question Requires Improvement. At this assessment, the rating has changed to Good. This meant people’s needs were met through good organisation and delivery. During our assessment of this key question, we found the provider had a good understanding of the local population and complied with the accessible information standards. They had arrangements in place to identify peoples’ communication needs and preferences. There were mechanisms in place for collecting and acting on patient feedback. The provider actively monitored the accessibility of their appointment system to ensure it remained patient focused.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice’s national GP patients survey results from 2024 showed people were treated with care, were listened to and had confidence with staff in line with local and national averages, including meeting mental health needs. People could feed back their experience of the service via Friends and Family Test (FFT) survey. We reviewed patient feedback and found consistent positive themes relating to co-ordinated person-centred care and clinicians listened to people and provided good quality care and treatment. Both clinical and administrative staff were described as professional and friendly. We reviewed the practice’s NHS UK patient feedback and found 8 feedback forms submitted in the last 12 months. The practice had received a majority of positive feedback with constructive suggestions in relation to person-centred care and patient access to services themes. The practice had where possible responded to people with bespoke correspondence.

Staff told us that there was a person-centred approach to delivering care and the service provided care in a way that was inclusive to improve accessibility to vulnerable patient groups. We saw evidence of patient feedback being collated and reviewed monthly with improvements to service provision where needed. Staff demonstrated awareness of how the practice considered patient preferences and how these were taken into consideration when co-ordinating care. Where appropriate, staff included carers and dependants in the planning of care and shared decision making about their treatment.

Leaders had a good understanding of the diverse health and care needs of their patient population. They told us that an analysis of local needs had been carried out at the primary care network level. We were told that many practice staff regularly took part in community engagement meetings and events and fed back to the rest of the team to encourage new initiatives for their patients.

Feedback from the community mental health team highlighted that vulnerable people were managed in a way to protect them from harm where possible and worked as a multi-disciplined team to develop treatment plans. Learning was shared across services based on regular evaluation of care. Feedback from local care homes indicated that people had access to the routine care and the practice home visiting team were able to provide urgent and acute care effectively.

There was an integrated approach to patient care, and services worked well together. Some services were offered onsite to support provision of care. Where referrals were made to external services, these were monitored and followed up appropriately.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area.

Staff demonstrated awareness of the practice subject access request processes and administrative tasks within the clinical records system were used to monitor the progress of providing information to patients in relation to their medical records. Staff told us that all consultations and treatments were carried out in the privacy of a consulting room. Curtains were provided in consulting rooms and treatment rooms so that patients’ privacy and dignity were maintained during examinations, investigations and treatments. We noted that consultation and treatment room doors were closed during consultations and that conversations taking place in these rooms could not be overheard.

The practice website contained accessible information on various service provisions such as, opening times, patient registration guidance, clinics and services, complaints, and ordering prescriptions. Reasonable adjustments were made at the practice to support communication, including the use of interpreters. Leaflets were available in the reception area and posters were displayed to provide patients with information on the practice and the different services available to them. Patients were also provided with information on how to access their medical records. A private room was available if patients were distressed or wanted to discuss sensitive issues. There were arrangements to ensure confidentiality at the reception desk and during telephone calls.

People reported having confidence and trust in their health professional from the feedback sources we reviewed. People reported that information was displayed clearly such as the practice website and within the premises to support people to share feedback, concerns or complaints.

Staff encouraged patients to share their experiences of the service. They supported patients to raise concerns and resolved them in a timely manner. Staff were able to provide examples of learning of how practice had improved from people’s experiences. Staff demonstrated awareness of the practice complaints process and how to assist patients with any concerns they had. Staff told us how learning from complaints was used as an opportunity for improvement.

There were effective systems and processes in place to capture the views of people, including complaints and incidents. Patients were proactively invited to share their experiences, we saw evidence of patient feedback themes that had been reviewed by the practice within the last 12 months. The practice valued peoples feedback and used it to inform how they introduced and reassessed changes. Staff were encouraged to attend management meetings where they reflected on learning from complaints, concerns and general feedback. During our assessment, we reviewed a sample of complaints and we found these were investigated and responded to appropriately in line with practice policy. Where appropriate, patients were provided with an apology and signposted to the Parliamentary and Health Service Ombudsman. There was also an annual review of complaints which looked at themes, learning points, changes made and other planned actions.

The practice’s national GP patients survey results from 2024 showed at times people found it difficult to contact the practice via telephone and online, with the practice scoring lower than local and national averages. As part of the assessment process, we reviewed feedback on care we received from practice patients in the last 12 months. Although feedback was largely positive, we identified themes of challenging experiences in relation to long telephone waiting times and dissatisfaction with appointment availability.

Leaders demonstrated they were aware of the challenges to patient access and had acted to improve patient access. Surveys had been carried out in relation to patient satisfaction with appointment preferences. We saw evidence of audits completed in relation to access performance, such as appointment capacity and demand data, telephone waiting times, appointment waiting times and patient ‘Did Not Attend’ (DNA) rates per GP in order to assess performance. This also helped provide oversight to rota management and staffing arrangements to meet access demand. Staff told us that there were opportunities to raise service improvements and actions had been taken as a result to improve patient pathways and access. For example, the practice had reviewed online triage, to streamline patient requests to designated clinical teams so that people could receive care and treatment by the right person at the right time. Leaders explained they provided opportunities and support for different groups of patient population to overcome health inequalities. For example, leaders would identify frequent contactors via telephone audits and offer a more co-ordinated package of care, including referral to the social prescribing team where needed. The leaders promoted the use of their website and online consultation service to improve access and online forms were available to be submitted to the practice for urgent and routine care needs. Feedback from staff demonstrated people in vulnerable circumstances were easily able to register with the practice and offered further support where required, including carers, people with learning disabilities and those with no fixed abode such as homeless people and Travellers. Staff told us they had completed relevant awareness training in supporting people with learning disabilities, autism, dementia and care navigation.

Patient appointments were available either online, face to face, telephone, or as a home visit. Patients could book appointments by telephone, online, walking-in and could also submit medical or admin requests online via the practice website. Cover arrangements were in place and a duty GP available, which included any urgent or follow-up care. Patients could book routine appointments up to 4 weeks in advance and same-day appointments were available. The practice offered appointments from a variety of clinical staff, for example GPs, health care assistants, pharmacists and practice nurses. The practice offered extended access arrangements outside of normal working hours provided by a GP and a nurse practitioner on Saturday mornings and weekday evenings. The practice had offered people who were cared for at home and could not access the practice a routine proactive care review. The practice had arrangements in place for prioritising people based on need, including those in palliative care. The practice had reviewed and audited telephone access data which included the total number of inbound calls daily; queue waiting times and call abandonments. We identified documented actions that had been taken to improve access to services such as additional administrative cover during increased demand and adjusting patient communication on the telephone queue system during busy periods and callback functionality. The practice had utilised Primary Care Network (PCN) resources to provide a co-ordinated package of care, such as mental health practitioners, first contact physiotherapists and pharmacy technicians.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received, we saw no indication of concern in this area.

Staff told us they considered how they tailored care, support and treatment to individual needs. Staff told us that if families had experienced a bereavement, the practice contacted them and an appointment was offered to discuss any further needs. Families were signposted to relevant support groups, such as the practice mental health support workers and social prescribers.

The practice met the accessible information standard to ensure all people, including those with communication needs could receive effective care and treatment. The practice was able to demonstrate reasonable adjustments under the Equality Act 2010. The premises had a portable hearing loop in place for patients with hard of hearing. Accessible communication formats such as large print materials and in easy read formats was available when required. Interpretation services were available. The practice held a register of patients who were carers and offered annual health checks. We saw examples of local care initiatives to help support carers in the community.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area.

Leaders understood the requirements of legislation when considering consent and decision making and had access to policies to support them. Staff supported patients to make informed decisions about their future, including at the end of their life. Patients on the practice palliative care register and were reviewed in monthly multi-disciplinary meetings. Staff told us how they worked with patients, and their carers, to support them to understand their options regarding Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions.

Staff were trained and had guidance to review and ensure specific care plans were identified for people to ensure their resuscitation and emergency treatment wishes were known. The provider had access to annual training for staff in relation to mental capacity act and learning disabilities and consent.