Naseby Medical Centre

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• 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

The Responsive key question has been rated Good. All quality statements for this key question were included in this assessment: Person-centred care, Care provision, integration and continuity, Providing information, Listening to and involving people, Equity in access, Equity in experience and outcomes, and Planning for the future.

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.

Feedback from the National GP Patient Survey results demonstrated that 84% of patients surveyed felt their needs were met during their last general practice appointment. In addition, 86% of patients surveyed felt they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment; and 73% of patients said the healthcare professional they saw or spoke to was good at considering their mental wellbeing during their last general practice appointment. These results were in line with national averages. The practice provided us with results (unvalidated) of a Friends and Family Test survey from May 2024 which stated that 98% of patients surveyed were likely or extremely likely to recommend the practice to friends and family if they needed similar care or treatment. Prior to our assessment CQC received four complaints from patients about the practice. These complaints included concerns about access to the service; inequalities of experience for patients with learning disabilities where reasonable adjustments were not made; poor staff attitudes; and poor clinical care and monitoring. As part of this assessment, we spoke with patients at the practice and feedback we received regarding patient satisfaction with the service was mixed.

Staff told us how they listened and responded to patients needs when making appointments and had undertaken care navigation training to help ensure when patients contacted the practice, they were guided to the right service to receive the right care for them. In addition, staff told us they worked closely with the GPs which facilitated any clinical advice required to book appointments appropriately for patients and signpost them effectively.

Leaders took steps to understand the diverse health and social care needs of their patient population. The practice provided us with minutes of multidisciplinary meetings with external stakeholders and services, for example health visitors and midwives, to facilitate co-ordinated and joined-up care for patients.

As part of our assessment, we asked the local Integrated Care Board (ICB) and Primary Care Network (PCN) for feedback about the Practice. The ICB raised concerns regarding the practice’s responsiveness to appointments and telephone access for patients. They also reported experiencing a lack of engagement and communication with the ICB in general; and a resistance to change such as with regards to the national cervical screening system, and the clinical IT system and cloud-based telephony system. The PCN told us that since joining their network, the practice had upgraded their clinical IT system in line with the majority of practices within the network. They also told us the practice had worked with the PCN to provide enhanced access for the patients across the network to allow better access to primary care services; and had been able to use funding to improve the uptake of immunisations and vaccinations. The practice was also working with the PCN as part of their health and equalities workstream.

The practice had a referral policy in place to facilitate patient care being joined-up, and supportive of patient choice and continuity. However, our review of clinical records found not all patients were appropriately monitored and followed up when referred to external services such as patients referred to diabetes clinics.

We did not receive any patient feedback related specifically to this area as part of our assessment however, the National GP Patient Survey however found 95% of patients felt the healthcare professional they saw had all the information they needed about them during their last general practice appointment.

Staff provided us with evidence to demonstrate the efforts made by the practice to ensure patients could access information in a way that they can understand, and which met their communication needs. For example, leaders had recruited reception staff who were multilingual and from the local community. The practice website provided useful health information for patients and included accessible online tools such as the ability to change the font size, navigate the website using speech recognition software, and listen to the website with the use of a screen reader. These facilities helped patients with visual impairments to access the practice website. Staff told us information was available to patients in different formats and they would highlight on patients’ records if they had any communication or accessibility needs.

There were policies and procedures for staff to follow to ensure patients had information that was tailored to individual needs. Interpreting and translation arrangements were in place for people who don’t speak English as a first language and for Deaf people who use British Sign Language. There were systems to ensure information about patients that was collected and shared met data protection legislation requirements.

Feedback from the National GP patient survey results demonstrated that 85% of patients said the healthcare professional they saw or spoke to was good at listening to them during their last general practice appointment. In addition, 86% were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. These results were in line with the national averages. Prior to our assessment however, CQC received 4 complaints from patients about the practice. These complaints included concerns about access to the service; inequalities of experience for patients with learning disabilities where reasonable adjustments were not made; poor staff attitudes; and poor clinical care and monitoring.

Staff we spoke with understood the complaints process and how to assist patients with any complaints or concerns they may have. Leaders told us that complaints were reviewed every six months and discussed in practice meetings to share learning; and they provided us with minutes of a complaints review meeting. The practice had received 4 verbal and 1 written complaint in the last 12 months and patients were responded to in a timely fashion. Staff told us they collated feedback via the Friends and Family Test to make improvements to the service. The practice had Patient Participation Group (PPG) to facilitate gathering further patient feedback. The PPG met approximately every six months, and we were provided with minutes of meetings where the national GP patient survey results and the practice building extension and refurbishment were discussed. Leaders told us they were exploring ways to increase the PPG membership. Leaders told us they listened to and acted on feedback and were trying to improve services. For example, the practice had upgraded the telephone system and introduced an additional phone line. The practice had also undertaken a PCN capacity and access piece of work where an analysis of telephone call volumes was undertaken which identified peak call times were between 10am to 12pm to answer telephone calls. To try to improve telephone access for patients, the practice had arranged for one of the reception team to solely answer telephone calls during this time period.

The practice had a complaints policy which detailed appropriate timescales for responding to complaints and identified nominated staff members for leading on handling complaints. Information about how to complain was available within the practice and on the practice website. Patients could make a complaint in person, by telephone, or in writing. Complaint forms were available at reception or could be posted to patients if required.

Patient feedback was mixed with regards to their experience with access to the practice. We found that patient feedback regarding access to care and treatment was lower than national averages for how easy it was to get through to someone at their GP practice on the phone. The National GP Patient Survey reported that 37% of patients found it easy to get through to the GP practice by phone which was below the national average of 50%. Prior to our assessment CQC received 4 complaints from patients about the practice which included concerns about telephone access to the service. As part of our assessment, we asked the ICB for feedback about the practice and they raised concerns about telephone access for patients. As part of our assessment, we spoke with patients at the practice and some patients told us they experienced very long waits trying to get through to the practice on the phone. In addition, the National GP Patient Survey found 55% of patients felt they waited about the right amount of time for their last general practice appointment which was below the national average of 66%. However, the National GP Patient Survey also reported that 46% of patients found it easy to contact this GP practice using their website which was in line with the national average of 48%. In addition, 63% of patients surveyed were offered a choice of time or day when they last tried to make a general practice appointment which was above the national average of 53%.

Staff were aware of the National GP Patient Survey results of 2023 which found that 17% of patients found it easy to get through to the GP practice by phone. In response to these results, staff told us they had upgraded the telephone system and had introduced an additional phone line. In addition, the practice had undertaken a PCN capacity and access piece of work where an analysis of telephone call volumes was undertaken which identified peak call times were between 10am to 12pm to answer telephone calls. To try to improve telephone access for patients, the practice had arranged for one of the reception team to solely answer telephone calls during this time period. In addition, staff told us they had advertised in the practice and on the practice website, the facility to book appointments online and had been advising patients to register to book appointments online. Staff were aware of the National GP Patient Survey results of 2024 and recognised there had been an improvement in these results for telephone access from 17% to 37%, but acknowledged this result was still below the national average. Leaders told us that as part of the proposed building extension and refurbishment of the practice, there were plans to add 2 additional rooms to the practice to increase the capacity for staff recruitment which would reduce telephone congestion and increase the availability of appointments.

Patients could book appointments by telephone, online, and in person by visiting the practice. All reception staff had received training in Care Navigation to help to ensure appointments were booked with the most appropriate service. Appointments were available face to face, by telephone, or as a home visit. Same day appointments were available, and patients could also book routine appointments in advance. The practice is open 8am – 6:30pm Monday to Friday. Doctors’ surgeries are held every day between the hours of 9:30am to 12:30am and 4pm to 6:30pm except on Thursdays. On Thursday afternoon, between 1.00pm to 6.30pm, an emergency out-of-hours service was provided by Badger Medical Services.

The National GP Patient Survey found 67% of patients described their overall experience of the practice as ‘Good’ which was below the national average of 74%. 79% patients said the healthcare professional they saw or spoke to was good at treating them with care and concern during their last general practice appointment which was below the national average of 85%. 73% of patients said they found the reception and administrative team at the practice were helpful which was below the national average of 83%.

Prior to our assessment, CQC received 4 complaints about the practice and 1 complaint raised concerns about inequality of experience for patients with learning disabilities where reasonable adjustments were not made.There were some systems in place to support patients who face communication barriers to access treatment (including those who might be digitally excluded). For example, interpreter services were available for patients whose first language was not English, and there was a hearing loop in place to support patients with hearing impairments. However, we found the practice premises required improvement in some areas to support equity in experience and outcomes for patients. There was a ramp at the practice entrance however, there was no automatic door to assist patients using wheelchairs to access the building entrance and no doorbell facilities to alert staff if a patient with a disability needed assistance to gain access to the practice building. A new doorbell was fitted shortly after the assessment visit. There were consulting rooms located on the ground floor and doors were wide enough to facilitate wheelchairs. Although the corridors met the minimum requirements for wheelchair accessibility, the upcoming building work plans included widening the downstairs corridors to improve wheelchair accessibility. The disabled patient toilet had appropriate handrails to assist patients and emergency call facilities were available.

Leaders sought ways to address any barriers to improving people’s experience and outcomes and provided us with evidence of architect plans for a building extension and refurbishment of the practice. These plans included an extension to gain 2 additional clinical rooms to increase the capacity to employ more PCN staff such as PCN pharmacists, physiotherapists, social prescribers and nurses. Leaders also explained the practice refurbishment included improving accessibility for patients with mobility problems such as widening of the corridors; lowering of the reception table; widening and improving accessibility from the main entrance to the waiting area; and improving accessibility from waiting room to the treatment room on ground floor. The architect plans also included an area for accessible parking. Leaders were confident that the refurbishment would meet current NHS standards or newly built health centres. GPs told us of current processes to improve equity in experience and outcomes for patients which included offering double appointments at the end of clinics for patient with complex needs; directing patients with autism and mental health problems to the waiting area upstairs in the practice which was quieter; providing home visits for frail patients; and co-ordinating with local pharmacies to ensure housebound patients had their prescriptions delivered to them.

Staff had received equality and diversity training. The practice had processes to ensure people could register, including those in vulnerable circumstances such as homeless people and Travellers. The practice website provided information and links to support organisations for transgender patients and we observed posters in the waiting area for an LGBTQ+ mental health and wellbeing service.

We did not receive any patient feedback which directly related to planning for the future however results of the GP National Survey showed 53% of patients felt they had enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses which was below the national average of 68%.

There was limited evidence to demonstrate that staff made sure when people wanted to express their wishes about cardiopulmonary resuscitation, they were supported to do so and were able to change their mind if they wish. GPs told us there was one patient currently who had a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form completed for them and this had been arranged by the palliative care team. GPs told us they would review a patient’s ReSPECT form every 6-12 months however they would not routinely review this form if a patient had been admitted and discharged from hospital.

There were registers held for those patients who were on the palliative care register or at the end of their life. There were systems in place for staff to keep up with training, including Mental Capacity Act, Deprivation of Liberty, and safeguarding training.