Healey 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 all quality statements in this key question.

We found staff treated people equally and without discrimination.

The gathering and recording of complaints were not managed in keeping with best practice guidance and the provider did not have robust processes in place for reviewing and responding to feedback from people who used services.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People who commented confirmed that the care met their individual needs whether provided by a GP; GP Trainee or allied health care professionals at the practice and also when signposted to an alternative service. The main concern raised was communication and understanding why they were not seen by a GP as their first choice.

Staff and leaders gave examples of people receiving the most appropriate care and treatment for them and steps taken to make reasonable adjustments where necessary.

We found staff treated people equally and without discrimination.

The gathering and recording of complaints were not managed in keeping with best practice guidance and the provider did not have robust processes in place for reviewing and responding to feedback from people who used services.

The provider had not sought the opinion of staff about their experience of working for the service.

Leaders and staff identified ways in which people were treated as individuals, this included placing a flag on the records of people who needed particular support or longer appointments; access to GP’s and support for people preferred their consultation in a language other than English. Leaders were especially proud to discuss support and work with patients who were going through different phases of gender transition.

Staff told us they were flexible with their provision of care to meet the needs of their patients and described additional steps taken to contact and raise awareness about cervical screening and the childhood immunisation programme. The partners described the value of the social prescribing services available for their patients.

Partners fed-back that the practice made full and effective use of the social prescribing service which meant support for social and economic needs was provided when possible.

In the main, people’s care and treatment was delivered in a way that met their assessed physical needs and preferred means of delivery in relation to language and same-sex doctors.

The provider worked with services in a co-ordinated and responsive way.

All staff were responsible for all tasks, patients stated that administration staff were not always respectful in carrying out all the allocated tasks.

Processes were not in place to effectively monitor and address all shortcomings identified by patients.

People had no specific feedback in this area.

Staff and leaders described measures taken to ensure information was provided in accessible ways. This included recognising and supporting GP’s use their language skills during consultations.

Staff were aware of how to flag accessibility requirements and special needs.

We discussed access to easier to read policies and procedures, especially the complaints policy for patients, and speak-up guardian policy for staff, neither of which were service specific and did not provide clear easy to follow information or instructions.

Leaders told us patient could access an easy read version of the complaints policy online, however this was not the case when it was tested during the inspection.

The provider had up to date access to medical records and data protection policies and was registered with the Information Commissioner's Office.

Processes were in place to provide information in an accessible way when the need was identified. Accessibility needs were assessed and shared. Processes were in place and effort made to meet individual needs once identified.

There were processes to assist people who did not use English as their first language such as language line, interpreters and members of staff who were multilingual.

Staff had completed General Data Protection Regulation (GDPR) training.

Information about how to raise concerns was not fully accessible to patients. Information about how to raise concerns was seen at the practice, however, information was not available on the practice internet site, to ensure people could access means of providing feedback independent of visiting the practice.

A complaints policy was in place, but this was not specific to the practice, it did not provide an effective and accessible system for identifying, receiving, handling and responding to complaints.

People told us it was difficult to relate with front line staff.

The 2024 results, from the NHS National GP patient survey showed people were dissatisfied with the experience of contacting the GP practice but were satisfied with their health outcomes and interaction with clinical and allied health care staff.

The 2024 NHS GP survey results indicated that, with the exception of the clinicians, people found it difficult to deal with the practice. 68% said they found the reception and administrative team at this GP helpful and 41% described their experience of contacting their GP practice as good. These satisfaction figures are well below the local and national averages.

The patient participation group meeting notes, however, indicated that suggestions about improving access had been listened to, and they had been involved in the project to improve the phone system and also review how appointments were managed at the surgery.

Staff and leaders described measures taken to ensure information was provided in accessible ways. This included recognising and supporting GP’s use their language skills during consultations.

Staff were aware of how to flag accessibility requirements and special needs.

We discussed access to easier to read policies and procedures, especially the complaints policy for patients, and speak-up guardian policy for staff, neither of which were service specific and did not provide clear easy to follow information or instructions.

Leaders told us patient could access an easy read version of the complaints policy online, however this was not the case when it was tested during the inspection. We found that the complaints policy was not available on the practice website.

Leaders provided data from Healey Surgery internal patient feedback survey. This data was of little value because it did not include the questions asked or the topics patients were asked about, there was no analysis of lessons learnt from the survey, furthermore, it was undated.

Information about how to raise concerns was not accessible to patients. There were no leaflets or posters at the practice and the information was not on the practice internet site. Leaders depended on administration staff to inform the patients of the complaint process and felt it was sufficient for patients to know that they could raise concerns directly to the partners, how this was to be communicated was not formalised.

A complaints policy was in place, but this was not specific to the practice, it did not provide an effective and accessible system for identifying, receiving, handling and responding to complaints.

Processes were not in place so that leaders responded to all the information available to them about the patients experience of the practice.

Leaders had access to up to date medical records and data protection policies and was registered with the Information Commissioner's Office.

Processes were in place to provide clinical information in an accessible way when the needed. Communication accessibility needs for appointments were assessed and shared. Effort was made to meet individual needs once identified. For example processes used to assist people who did not use English as their first language included use of language line interpreters and members of staff who were multilingual.

Staff had completed General Data Protection Regulation (GDPR) training.

In the main people told us they could access care, treatment, and support when they needed to. However this was not always in a way which worked for them. For example, 25% of people who responded to the 2024 NHS GP patient survey felt they were offered a choice of time or day when they last tried to make a general practice appointment. This response is well below the local response rate for practices local to Healey Surgery where, on average, 55% of patients said they were offered a choice.

Although people described responsive treatment, some expressed dissatisfaction with the attitude of administration staff and felt there was a lack of opportunity to see who they wanted to and when.

Leaders told us they had started to allocate staff to different tasks to improve efficiency. Allocated tasks included making calls to remind people about appointments.

We were informed that flags were in place to identify people who needed additional assistance, and this information had been updated as people visited the practice.

However, feedback from leaders also indicated they were not fully aware of the barriers some people may have accessing the service, for example we discussed with them that the patient-list had fallen from approximately 8000 patients in 2018 to 6253 patients in September 2024, when, on average, patient-list sizes have steadily risen in the same period.

We found this was not a planned reduction, however the reasons had not been looked into. Leaders put forwards various explanations but no evidence of a proactive investigation or documented discussion about the cause, the impact on the local community or action taken to stop the fall in patient numbers.

People could make an appointment by calling the practice or attending the practice. Patient appointments were available either face to face, on the telephone, or as a home visit.

Leaders shared a list of actions taken as a result of an internal audit into access, this included arrangements for patients to use Access Service clinics. Appointments were made through contacting Healey Surgery and choices for face to face or telephone consultations were available at times when the practice is closed. The Access Service is in close proximity to the Healey Surgery and open daily, including Saturday, Sunday and Bank Holidays and also weekday evenings.

The practice also used the acute visiting scheme service to facilitate out of hours home visits.

Changes had also been made to the management of appointment bookings and the length of appointments.

The provider was working with the Primary Care Network to upskill a paramedic into the role of GP Assistant. (GP Assistants provide a support role, carrying out administrative tasks, combined in some areas with basic clinical duties.)

To improve people’s experience, an advanced Cloud based telephone system had been installed which allowed patients to request a call back instead of waiting on the phone and also informed them of their position in the queue.

However, the patient list was falling and a possible explanation given by the leaders concerned a problem with equity of access due to staff incorrectly removing or refusing registration based on the patients postcode.

People did not comment about equity in experiences and outcomes.

Leaders described their understanding of the importance of providing an inclusive approach to care, they stated that all action was taken to ensure patients had access to the interpreters if needed and indicated that they ensured sufficient female clinicians in place for woman who preferred to see a clinician of the same sex. A chaperone was routinely offered to patients who might benefit from this.

The provider had processes to ensure people could register at the practice, however leaders had not assured themselves that the relevant staff understood this.

There was evidence that systems to capture and review feedback from people who did not have access to the internet was in plac, hwoever, leaders did not demonstrate that all information available was used effectively.

People had no specific feedback about this topic.

We did not receive specific feedback from staff and leaders about supporting people to plan their future.

People were supported to plan ahead for important changes in their lives. We saw evidence staff acted without discrimination when supporting people and their families to make decisions.

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.

Processes in place to ensure external services were involved or updated when needed were effective.

Systems were in place to ensure essential funeral rites could be respected.