Abbey Field Medical Centre

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 all the quality statements from the responsive key question. Due to our change in methodology, our rating for this key question has improved from requires improvement to good. At this assessment we found the provider had a good understanding of the needs of the local population and had developed services in response to this. Arrangements were in place to identify people’s communication needs and preferences and we found staff treated people equally and without discrimination. People were involved in decisions about their care and treatment and were provided with advice and support, which included planning for the future. There were mechanisms in place for collecting and acting on people’s feedback. However, feedback from people was mixed and some people reported difficulty accessing an appointment and accessing the practice by telephone. Some improvements had been implemented and further improvements were planned, but these were not sufficiently embedded to be able to demonstrate positive impact on people, at the time of the assessment.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Feedback from the friends and family test, and feedback collected by CQC, was mostly positive and included comments about being listened to, and the helpfulness of staff. Care home staff told us some people were seen at home and others at the practice, due to their individual needs and preferences. The 2023 national GP patient survey results showed 95.5% of people stated they were involved as much as they wanted to be in decisions about their care and treatment.

Staff told us about the arrangements in place to identify people’s communication needs and preferences and offered interpretation services for those people whose first language was not English. Staff told us information was available in relation to understanding and supporting the different cultural and religious needs of people, so they were able to provide person centred care and treatment. Staff worked closely with a homeless charity and explained the process for registering people with no fixed abode. Staff told us about the arrangements they had in place to support person centred care. Examples included working with local organisations which support homeless people, the LGBTQ+ community and refugees.

Leaders had a good understanding of the needs of the local population and provided a range of services at the practice sites. These included for example, adult and childhood mental health teams, a first-contact physiotherapy service and a monthly dementia coffee morning. Staff told us that people could request to see a GP of their choice or choose to see the same GP for follow up, although this may be a longer wait. Staff were able to offer people the option of being seen in the extended access clinics. These were open until 8pm 3 evenings a week and on Saturdays from 9am to 5pm, and staff could book people directly into these appointments. People who were over 75 had a named GP who supported them in whatever setting they lived. Arrangements were in place to ensure continuity of clinician for people who lived in a care home. Weekly visits and calls were made to people living in a care home and people were assessed and reviewed as appropriate.

We received positive feedback from partners in relation to how practice staff worked with them to increase the availability and provision of services. Examples included podiatry, a fitness programme, and a dementia café, where the Royal Horticultural Society also held wellbeing gardening workshops.

Practice staff had a range of clinics, services and organisations they signposted and referred people to. For example, staff actively referred people for support with their wellbeing and social issues to a social prescriber or senior social prescriber, who were employed by the practice. Leaders had systems in place to review the services received from other organisations and took action to make sure they were supporting the needs of people registered at the practice. Arrangements were in place to support people whilst they were waiting for secondary care appointments. The Primary Care Network (PCN) were currently recruiting to a tissue viability nurse position to work across the PCN practices.

Feedback from the friends and family test, and feedback collected by CQC, was mostly positive and included comments about knowledgeable staff who answer questions well and explain the plan of care and treatment. Care home staff gave examples when information for medicines and health check appointments were given in an easy read format.

Staff told us some information was available to people in different formats and it would be highlighted on people’s record if they had any communication or accessibility needs. This information was gathered at the point of registration and opportunistically. The practice were in the process of developing a pictorial booklet to help people who needed additional support to attend an appointment at the practice.

The practice had an accessibility statement on their website and there was a range of information available at all practice sites. This included information in larger text, pictorial and inclusive information. There was a photo board of staff members at each practice site. All sites had hearing loops available. Interpreter services were available for those people whose first language was not English.

Feedback from the friends and family test, and feedback collected by CQC, was mostly positive and included comments about how people were involved in their care and treatment. Care home staff told us they were appropriately involved and were usually listened to when they gave feedback. There was an active patient participation group (PPG) who met with practice staff every 2 months and represented the views of people using the service. Representatives from the PPG described how managers and PPG members had made positive changes because of feedback. The practice shared 27 compliments received from people between 5 April and 11 July 2024, thanking a wide range of staff across different teams, for their support, care and treatment.

Leaders told us that they would speak to any person who was in the practice and was not happy or would phone them and invite them in to discuss their concerns. Staff gave examples of feedback from people which had been acted on, for example, turning the radio off in the reception area when the television was on, due to the noise being overwhelming.

The practice had a complaints policy and kept a log of people’s complaints, which they used to review themes and trends. We reviewed 4 complaint responses and found these were dealt with appropriately. The practice had a complaints leaflet which included advocacy information and details of where to escalate their concerns if they were not happy with the practice’s response to their complaint. Complaints information leaflets were easily available in the practice waiting rooms and were also available on the practice website. Feedback from the friends and family test were reviewed monthly and we saw records from July 2017 to June 24. All comments were reviewed, and actions taken in response to feedback, where possible.

We reviewed the National GP patient survey, published in July 2023. The 4 indicators for access were in line with the England averages and had improved in these areas in the previous year. Care home staff were generally satisfied with appointment arrangements. Some received a weekly call to identify if any people needed to be assessed or reviewed, which was arranged, and others also received a regular weekly visit. Feedback from the friends and family test, and feedback collected by CQC, was mixed in relation to access to appointments. Some people reported difficulty accessing an appointment and accessing the practice by telephone. Some people gave feedback that they were not seen on time or did not receive telephone consultations as planned. Some people told us there could be a wait for non-urgent appointments although they were satisfied with the timescale and how their non urgent appointment was managed.

Appointments were available between 8am to 6:30pm on 2 days of the week, until 8pm on 3 days of the week, and on Saturdays from 9am to 5pm. Appointments could be made in person, via telephone or online. All appointment requests were triaged with people booked into an appointment or people were signposted elsewhere, for example to a pharmacy, as appropriate. Urgent requests were booked into an appointment with a clinician or triaged by a duty doctor and responded to as appropriate. People with the most urgent needs had their care and treatment prioritised. The practice was responsive to the needs of people who were too ill or physically incapable of traveling to the practice and offered home visits, and urgent appointments for those with enhanced needs and complex medical issues. Practice leaders confirmed appropriate arrangements were in place when telephone consultations were not able to be undertaken as planned, due to people not being contactable. All consultations took place on the ground floor level. Practice leaders told us they were aware of feedback from people regarding issues with access and they regularly monitored access data. The online communication system between people and practice staff, which included an online consultation tool had been embedded. They were currently communicating with people, engaging with and training practice staff in order to introduce total triage from October 2024. This is a system where every person contacting the practice will advise on the reason for contact and will be triaged to decide the best response.

The practice had systems to monitor, review and understand their access data. Practice leaders were working with their Primary Care Network (PCN) and the Integrated Care Board (ICB) in relation to improving capacity and access. Quarterly surveys of people using the service had been undertaken in relation to access. The results were reviewed and actions to improve access were agreed and monitored. In response to the issues regarding telephone access, a new phone system was installed in August 2024. Benefits included for example, people being able to hold their place in a queue without holding on the line and enabling call data to be monitored and further action taken in response, as appropriate. The practice were in the process of moving to a total call triage system from October 2024 to further improve access and improve equity of access. However, at the time of this assessment these processes and arrangements were not in place or sufficiently embedded to be able to demonstrate improvement or positive impact for people who used the service.

Feedback from the friends and family test, and feedback collected by CQC, included comments about how support, care and treatment was tailored to people’s needs. Care home staff gave examples of where services were tailored to the needs of the people they supported, for example weekly calls and visits. We received positive feedback from partner organisations with regard to the compassion, care and comprehensive health service provided to people who they supported and who were homeless.

Leaders and staff 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 made adjustments to support equity in people’s experiences and outcomes. Staff told us about the arrangements they had in place to support inclusivity. The practice had an inclusivity lead, who gave examples which included working with local organisations which support homeless people, the LGBTQ+ community and refugees to promote equity in experience and outcomes.

The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people, asylum seekers and refugees. The practice had an inequalities lead, whose role was to make the practice more inclusive for everyone. Examples of achievements included LGBTQ+ campaigns being promoted on the practice’s social media platform, cervical awareness week promoted to transgender people and information on people’s pronouns shared throughout with practice. Nearly all staff had completed learning disability and autism awareness training, which included face to face training.

Care home staff were satisfied with the support from the practice and community nurses in supporting people to plan for their future and in meeting their current end of life care needs. We did not receive any feedback or concerns from people regarding the arrangements in place.

Staff told us they attended regular palliative care meetings where people who were receiving end of life care were discussed and reviewed. Some clinical staff had previous experience in palliative and end of life care and told us the practice used their skill and expertise appropriately. 1 of the practice leaders told us about a ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) audit which had been completed in November 2023. Work had started to promote and encourage the use of ReSPECT, with people being identified in order of priority, given time to have conversations with their family members and healthcare professionals, and record what matters to them and what is realistic in terms of their care and treatment.

The practice had systems in place to support people at the end of their life. The provider held regular palliative care meetings which were attended by the practice clinical lead and administration lead, care home and hospice staff, and a GP care advisor. People who were receiving palliative and end of life care were discussed and reviewed as appropriate. The service also offered home visits where appropriate. There were clear systems and processes in place for ensuring people’s decisions in respect of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) were made in line with relevant legislation and were appropriate. There was a process in place to ensure DNACPR forms were reviewed when the person’s condition or circumstances changed. We reviewed the records of 2 people, which included 1 person who had a DNACPR decision in place and 1 person who had a ReSPECT (Recommended Summary Plan for Emergency Care and Treatment). Both had been completed appropriately following national guidelines.