Dudley Wood 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

At the last inspection we found that 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 were not used to drive continuous improvement. At this inspection we found that the practice had taken action to respond to patient needs. Improvements had been made so people could access services when they needed to, without physical or digital barriers, including out of normal hours and in an emergency. The practice website had been improved for online access to appointments. 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. The provider prioritised, allocated resources and opportunities as needed to tackle inequalities and achieve equity of access. At the time of our inspection a new telephone system was being installed to improve access further and complaints were being used to drive continuous improvements. There were 3 reviews from NHS UK since our last inspection who found staff helpful, polite, professional and approachable.

This service scored 68 (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 told us that they regularly involved patients in planning and making shared decisions about their care and treatment that meets their needs. Staff had been trained in equality and diversity, consent, deprivation of liberty safeguards and mental capacity. Feedback about the overall experience of using the service was positive, particularly in relation to feeling listened to and being treated with care and concern. The practice had reviewed feedback about the quality of care provided and used this to make improvements.

The GP lead told us how they worked with local community services for health promotion and to deliver services to support care and treatment.

The practice understood the needs of its local population and were taking action to develop services in response to those needs. There were regular meetings held with community services for continuity of care, support and treatment. Through the Primary Care Network (PCN), the practice staff were able to offer patients access to other services such as social prescribing, dietician, physio, and mental health nurse to support their overall health and wellbeing.

Staff and leaders told us that they worked within the primary care network (PCN)and other agencies to ensure that people’s care and treatment is delivered in a way that meets their assessed needs and are responsive. For example, the practice was supported by a clinical pharmacist to ensure medicines management was appropriately monitored and there were regular PCN meetings to review vulnerable patients and to provide patients with coordinated care. The practice liaised with the community services to discuss and manage the needs of patients with complex medical issues and held registers of patients living in vulnerable circumstances including those with a learning disability, mental health or safeguarding concern.

The practice told us that they had reviewed their website to make this more accessible to their patients. The website included useful information on health awareness and promotion. Information and resources was available for patients to support them to understand how to access services. For example, there were arrangements in place for people who need translation services or who may be digitally excluded.

There were systems in place to support patients who face communication barriers to access treatment and patient records were held in line with guidance and requirements. We found the practice complied with the Accessible Information Standard and information about people that was collected and shared was in line with data protection legislation requirements.

Feedback from the patient survey results demonstrated that 80% of patients say the healthcare professional they saw or spoke to was good at listening to them during their last general practice appointment and 88% were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment.

Leaders told us that complaints were regularly reviewed and discussed in practice meetings to share learning. The practice had received 8 complaints in the last 12 months and there was evidence that appropriate action was taken. The practice told us they collated feedback via the Friends and Family test to make improvements to the service. In addition there were regular meetings with the patient participation group (PPG) on ways to improve the service.

The practice had a complaints policy in place and complaints were reviewed further and were responded to improve the quality of care. There were regular practice meetings where complaints and significant events were discussed to share learning to make improvements. Information about how to complain was readily available and patients could make a complaint in person, or via the practice website.

Patients could book appointments by telephone, online, and in person by visiting the practice. Appointments were available face to face, by telephone, or as a home visit. Same day appointments were available, and patients could book routine appointments up to 2 weeks in advance. Appointments with a GP were available throughout the week. Extended access was available every Tuesday from 6.30pm and 8.30pm. When the practice was closed patients were able to contact 111. The practice offered appointments from a variety of additional clinical staff for example nurses, health care assistant and pharmacist. Pre-booked appointments were available on weekday evenings and at the weekend through an arrangement with other local GP practices. The practice had arrangements in place for prioritising patients. Staff were trained to book appointments with members of the practice clinical team or signpost patients to other appropriate services and were supported by a duty doctor.

The practice were responding to the needs of their population and were developing services in response to those needs. The practice told us they obtained feedback from various sources such as the GP patient survey, friends and family complaints and via informal feedback from patients. All non-clinical staff were trained in care navigation. The practice undertook ongoing audits to determine demand and capacity regarding their appointment system and continued to monitor the availability of appointments and staff on a daily basis. The practice told us that they had reviewed their website and adjusted appointments with clinicians for routine appointments. In the 2023 National GP Patient Survey data was in line with national averages for 3 out of 4 outcomes relating to access. We found that patient feedback regarding access to care and treatment was significantly higher than national averages for how easy it was to get through to someone at their GP practice on the phone. Patients could access appointments by phone, online and by visiting the practice. The practice used a sign-posting triage system where reception staff would ask the patient for enough information to make a decision regarding which clinician was appropriate for them to see. Patients were given the option of a face to face or telephone appointment. Patients who had a request for an emergency appointment were seen the same day. The practice website provided information for patients regarding how to book an appointment. Feedback from staff demonstrated people in vulnerable circumstances were able to register with the practice, including those with no fixed abode.

Evidence reviewed in the last 12 months demonstrated that patients survey results had seen an overall 20% decline in the satisfaction of appointment types and times that were offered to patients. Leaders demonstrated they were aware of the challenges to patient access and had acted to improve access for people since the last inspection. The practice created an action plan in response to the annual National GP Patient Survey results. We spoke with members of staff in leadership and management roles. It was clear that improving access and patient experience was a priority for the practice and feedback had led the service to review performance and identify improvements. The leadership told us they had recruited additional clinicians and had reviewed their website to provide opportunities and support for different groups of the practice population to overcome health inequalities. Feedback from staff demonstrated people in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode such as homeless people and Travellers.

The practice had promoted and responded to feedback by people who used the service within the last 12 months. People could leave feedback via NHS choices, the practice website and via the Friends and Family test (FFT). The practice had received 504 responses to feedback for their FFT in March 2024 and 76% of patients found the practice to be excellent or good. We were provided with actions taken in response to poor feedback about the telephone system which equated to 7% and found that the practice were taking action to install a new telephone system with additional call back features.

The practice had an active PPG, which met with key staff members at the practice, quarterly. Areas discussed included, prostate cancer campaign, staffing, feedback from people who used the service, the practice website and online access. The provider complied with legal equality and human rights requirements, including avoiding discrimination, having regard to the needs of people with different protected characteristics and making reasonable adjustments to support equity in experience and outcomes, including meeting the Accessible Information Standard. We saw examples where the practice had met the needs of vulnerable patient groups and removed barriers for improved patient experience. For example, the practice premises had a hearing loop in place and access to interpreters was available. People with learning disabilities and poor mental health experienced additional care through annual reviews. People with dementia were referred to appropriate services where required.

Leaders told us that the practice had focused to address workforce challenges including wider clinical support through the primary care network (PCN) and through locum staffing to improve access arrangements for people using the service. We saw evidence that the lead GP had made contact with a local MP regarding NHS workforce challenges in primary care. Staff told us they were working to improve access through their website and the use of social media for health promotion. The practice regularly engaged with feedback from the Patient Participation Group (PPG) and had shared results from patient survey and friends and family test. The practice had also held a prostate awareness event attended by the local mayor and local musician.

There were systems in place to ensure staff kept up to date in training relating to the Mental Capacity Act and Deprivation of Liberty Safeguards. We found that all staff had completed the required training. There were registers held for those patients who were vulnerable who were on the palliative care register or at the end of their life. We found that clinicians understood the requirements of legislation and guidance when considering consent and decision making and saw that consent was documented. We found that since the last inspection, Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions were made in line with relevant legislation and were appropriate.

77% of patients told us that the healthcare professional they saw or spoke to was good at treating them with care and concern during their last general practice appointment and 88% were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment.

Leaders understood the requirements of legislation when considering consent and decision making and had access to policies to support them. We were told that the practice held multidisciplinary meetings with other agencies to share and discuss information relating to patient care and treatment, for example, those on the practice palliative care register.