Southway 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 assessed 6 quality statements from this key question. We found the practice did not always organise and deliver services to meet patients’ needs, patients could not always access appointments in a timely way and complaints and patient feedback were not used to drive continuous improvement.

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.

Patients we spoke to or received feedback from told us their individual needs were taken into account, and that healthcare professionals listened to them and helped them to understand their condition, care, and treatment options. However, patient feedback via the 2024 National GP Patient Survey (GPPS) indicated 68% respondents felt the healthcare professional they saw or spoke to was good at treating them with care and concern during their last appointment. This was below the local average of 88% and national average of 85%. GPPS feedback also showed 68% respondents find the reception and administrative team at this GP practice helpful. This was below the local average of 87% and the national average of 83%.

Leaders and staff told us they offered reasonable adjustments and took people’s individual preferences into consideration during appointments and when providing information. For example, providing information in formats to help patients understand their care, treatment and conditions as well as having access to interpreters.

Staff told us they held registers of patients living in vulnerable circumstances including those with learning disabilities, mental health and carers. We were unable to gain assurances that staff and leaders worked consistently with external agencies to ensure that people’s care and treatment was delivered in a way that met their needs and were responsive. For example, we saw limited evidence of engagement with external agencies such as health visitors, palliative care teams, district nurses or other agencies involved in reviewing safeguarding concerns. However, the practice informed us after the assessment that a representative from the practice attends an aging well meeting every 5 weeks which includes representatives from the district nursing team, care of the elderly consultant and community frailty team.

Feedback from a local partner stated that a weekly ward round at a local care home had been stopped in December 2023 and this led to less engagement between the residents, care home staff and the practice.

There were processes in place to ensure referrals made to external services were monitored and followed up. Safeguarding meetings were held at the practice, however, minutes contained limited information. For example, minutes did not show evidence of discussions with health visitors or other external agencies when safeguarding concerns had been highlighted.

Patients told us they were provided with enough information to understand their care and treatment, including different options available to them. Patient feedback via the 2024 national GP Patient Survey data showed 87% responding patients felt the healthcare professional they saw had all the information they needed about them during their last general practice appointment. This was in line with the local and national averages.

Leaders and staff told us individual communication needs were noted on the patient record, for example, if a patient required a hearing loop. We were told patients could access information in more accessible ways to ensure they understood their care, treatment and conditions, such as in large print. Leaders told us since June 2023 the practice had moved to an online triage system, requiring patients to complete an online form and we were told staff supported patients to complete this online form if required.

The practice website was accessible to patients and included useful health promotional material and resources as well as up to date information on opening times, appointments information, prescriptions information and new patient registrations.

Feedback from patients showed that most patients had not been offered any opportunity to share their views or provide feedback to the practice. Some patients were also not aware of how to raise a complaint with the practice. Patient feedback via the 2024 national GP Patient Survey data indicated 76% of respondents said the healthcare professional they saw or spoke to was good at listening to them during their last general practice appointment. This was below the local average of 90% and national average of 87%.

Staff told us patients were able to share feedback and raise complaints, however, some staff told us they were not made aware of learning or outcomes from complaints. Leaders told us patients provided feedback via the NHS Friends and Family Test and used this to drive improvements. However, the practice did not seek patient feedback in other formats, and we noted the practice had not responded to any feedback provided on the NHS UK website. We noted from the practice business development plan that the Patient Participation Group had suggested introducing an annual patient survey, however, this had not been included in the development actions to be completed.

There were processes in place for patients to share feedback and raise complaints about their care, treatment and support. From our review of practice complaints log, the practice had received 48 complaints in the last year. We reviewed two complaints and found these had been handled in accordance with the complaint policy. However, the information withing the complaints log was limited and could not be relied on for accurately tracking themes and trends. For example, a complaint had been raised that a baby had breathing difficulties and the practice asked them to complete an online appointments request form. This was raised during a clinical governance meeting but did not provide any detail on action taken including learning outcomes for staff. This incident had not been raised as a significant event.

The practice’s results for the National GP Patient Survey (GPPS) 2024 indicated that patient experience of access was below local and national averages. For example, 37% of respondents said they found it easy to get through to the practice by telephone. This was below the local average of 55% and national average of 50%. In addition, the GPPS showed 50% of respondents described their experience of contacting their GP practice as good. This was below the local average of 73% and the national result of 67%. From a review of NHS UK feedback on the service, we found that out of the 9 reviews displayed, 4 of these raised concerns regarding poor access to appointments. Feedback we received from patients was mixed. Some patients were satisfied with access to appointments whilst others told us it was difficult to book face to face appointments and said there was no telephone access for patients, and this has led to patients having to travel to the practice in order to book an appointment. We noted the recently formed patient participation group (PPG) discussed access at the first PPG meeting in July 2024 and a specific concern was raised regarding elderly patients using online access. However, minutes did not provide any further information or detail on this discussion point.

Feedback from staff and leaders demonstrated they were aware of some of the challenges to patient access, for example, the need for another permanent GP and told us they continued to try to recruit to this position. Leaders told us they moved to an online triage system in June 2023 and this meant patients wishing to have contact or book an appointment with a GP should complete an online form which is then reviewed and triaged by the duty GP. Leaders told us this meant patients were given the most appropriate appointment in the first instance and this had reduced appointment wastage. However, appointments to see the nurse or health care assistant could still be booked by telephone. The practice told us patients who were not able to use the online form were able to telephone the surgery and a member of staff would complete the form on their behalf. However, some patient feedback we received told us telephone access was a concern. In addition, the GPPS 2024 results showed 5% respondents usually get to see or speak to their preferred healthcare professional when they would like to. This was below the local average of 48% and the national result of 40%.

The practice opening times were Monday to Friday 8am until 6pm. Appointment types include telephone and face to face. The practice offered home visits and urgent appointments for patients where appropriate. We reviewed the practice appointment system and found the next available routine GP appointment was available in 3 weeks. Out of hours services were provided by another provider.

We did not look at Equity in experiences and outcomes during this assessment. The score for this quality statement is based on the previous rating for Responsive.

Patient feedback we received indicated patients were supported by staff to make informed choices about their care.

Staff told us they supported patients to make informed decisions about their future, including at the end of their life. Leaders told us they had 22 patients with an active Do Not Attempt Cardio Pulmonary Resuscitation in place.

We found the practice had a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) and End of life policy. However, we noted these were first version policies and had been created in July 2024. We did not receive evidence to demonstrate the practice attended meetings to discuss patients receiving palliative or end of life care.