Cardinal Medical Practice

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 from this key question. Our rating for this key question is Good. At this assessment we found improvements had been made since the previous inspection published May 2022. 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 their future. The provider had a good understanding of the local population and complied with the accessible information standards. There were mechanisms in place for collecting and acting on people’s feedback. Improvements had been made to staff involvement in the investigation of and learning from complaints. The practice had made improvements to access, particularly in accessing the practice by telephone and staff continued to review, monitor, and make changes to further improve people’s experiences in relation to access. They had also recently recruited 5 salaried GPs. However, feedback from people was mixed particularly in relation to difficulty accessing an appointment and accessing the practice by telephone.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The majority of people gave positive feedback about how their needs and preferences were taken into account when receiving care and treatment at the practice. Care home representatives told us care and treatment was based on people’s individual needs and preferences. People and where appropriate, family members and carers were involved in care and treatment decisions.

The practice had arrangements in place to support person centred care. When booking appointments, non-clinical staff asked people about their preference for clinician, site and time. People who were due a long term condition review could book their appointment online or by telephone on a date and time to suit them. Clinical staff told us during consultations they discussed relevant information, listened to people’s concerns and expectations, identified peoples’ needs and preferences and agreed a plan of care together which suited the person. Staff gave examples of when care plans had been adapted to the specific needs of people. The practice had a care coordinator who contacted people who were hard to reach, for example, people who had not responded to a long-term condition appointment invitation, or practice requests for monitoring of medicines. People were contacted by telephone initially, then by text message and then by letter. If no response was received these people were raised with a clinician so a clinical judgement could be made on the next steps.

Leaders had a good understanding of the needs of the local population and provided a range of services at the 3 sites. These included for example, a first-contact physio service, a diabetes specialist nurse and midwife appointments. 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. Arrangements were in place to ensure continuity of clinician for people who lived in a care home. Weekly visits and calls were made, and people were assessed and reviewed as appropriate. Clinical administrative work was assigned to people’s registered GP, so they had oversight and could provide guidance to other clinicians who may be dealing with the person. Practice leaders explained that the Integrated Care Board (ICB) had commissioned a phlebotomy (blood taking) clinic which was located the other side of Ipswich. The practice recognised this was not easy for people registered at the practice to travel to. The practice did schedule capacity for urgent blood tests to be undertaken at the practice.

We received positive feedback from partners in relation to how practice staff worked with them to increase the availability and provision of services. This included their work with care homes. The practice had an open culture and worked together with other services to better support people using the services.

Systems were in place to support continuity of care, for example, practice staff followed a continuity of care protocol. Staff booked follow up appointments with the same clinician or offered people their choice of clinician. Systems were in place to ensure people were seen by an appropriate clinician if needed. For example, if a person had been seen twice by an Advanced Nurse Practitioner for the same issue with no improvement, then the next appointment was booked with a GP. Clinical administrative work was assigned to people’s registered GP, so they had oversight and could provide guidance to other clinicians who may be dealing with the person. Practice staff had a range of clinics, services and organisations they signposted and referred people to. Information was also available on a range of services people could self-refer to, which included for example, carer support, drug and alcohol, mental health, sexual health and youth counselling services.

We received no specific feedback from people regarding their experiences for this quality statement. Care home representatives gave examples when information was given in suitable formats for people’s needs.

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. Staff were aware of the arrangements in place to book an interpreter.

The practice shared a link on their website to the NHS accessible standards information which included how people can make the practice aware of their specific communication needs. Information about people’s specific needs including any reasonable adjustments in place, was available on the practice online access and computer system. People with communication needs were supported. For example, letters had been translated to different languages and were available for use. Staff had access to communication aids to help people become partners in their care and treatment. Interpreter services were available for those people whose first language was not English, and for people with a hearing impairment. All sites had a hearing loop available and reception staff were able to support people to use them, if needed. The practice has some staff who spoke multiple languages and staff offered appointments with those staff members according to people’s preferences. At 1 site a range of information was displayed in the main languages spoken by people who used the service. This included for example, information about how to register, prescription requests, chaperones and health information.

People told us they were involved in decisions about their care, and we did not receive any negative feedback from people relating to how the practice managed complaints. Care home representatives told us they were appropriately involved and were listened to when they gave feedback. A Patient Participation Group (PPG) representative described how practice leaders listened to and acted on most of the feedback shared. For example, improvements had been made to the telephone system, with people being able to request a call back rather than wait in the queue. The practice had recorded 75 complaints in the previous 12 months. Themes included people not being listened to, poor access, and poor clinical assessment, care and treatment. Of these, 14 were upheld, 20 partially upheld and 41 not upheld. The practice had recorded 62 compliments in the previous 12 months. Themes included people being listened to, professional, helpful and caring staff, good access and thorough clinical assessment, care and treatment. The practice also collected feedback from the friends and family test. In the previous 12 months, 70% of people responded good or very good to their experience of the service.

Leaders told us that the practice took complaints seriously. They offered to speak to any person who was not happy in the practice, would arrange to telephone them, or would invite them in to discuss their concerns. Staff were aware of the complaints procedure and how complaints information could be accessed if people asked them. Staff gave examples of feedback from people which had been acted on, for example, sending people a code so they can book an appointment themselves at a convenient day and time, people being able to submit some requests online outside of practice opening hours and the successful recruitment of 5 new salaried GPs. Staff told us there were processes in place to ensure both positive and negative feedback about the practice was shared with the individuals and the practice team.

The practice had employed an Access and Digital Care Co-ordinator who monitored and responded to online feedback to help support and educate people to access appropriate and timely healthcare and advice. The practice had a complaints leaflet which included information about the complaints process, support organisations and details of where people could escalate their concerns if they were not happy with the practice response to their complaint. The practice had a complaints policy and kept a log of complaints which they used to manage complaints and review themes and trends. The complaints we reviewed had been managed appropriately. They were documented formally, investigated and people were responded to in a timely manner. People received a final response which included contact details of the Parliamentary Health Service Ombudsman if they wanted to escalate their complaint. Any learning from complaints was identified and monitored to completion in a timely manner. Practice reflection and learning meetings were held in addition to risk management meetings, where complaints, compliments and near misses, and all outcomes were shared with the wider practice team.

We reviewed the National GP patient survey, published in July 2024. The 2 indicators for access; describe your experience of contacting your GP practice on this occasion, and how easy or difficult is it to contact your GP practice on the telephone, were below the England average. 68% of people responded good or very good to their experience of the service from October 2023 to April 2024 (when the new telephone system was installed). From May 2024 to November 2024 the average had increased to 73%. Feedback we received from people was mixed regarding access. Some people found improvements had been made to access by using the online access system and also with the call back facility on the new telephone system. However, some people did not find accessing an appointment easy. There was positive feedback regarding access for children. Feedback from representatives from 3 care homes was positive regarding access. This included planned weekly visits and also additional visits for people with urgent needs. A separate telephone line was available if needed, for requests to be made.

Practice leaders told us that they had listened to feedback from people who used the service with regard to access and had implemented new systems and ways of working to try to improve it. This included improvements to both their online access and telephone system. For example, the new telephone system enabled people to request a call back, so they did not have to wait on the line for the call to be answered. Staff also gave other examples, which included multiskilled staff who prioritised answering telephone calls at peak demand times. Leaders told us they had successfully managed to recruit to all GP vacancies. An online access system was in place, and all requests were submitted through this system. People who were not able to go online, could telephone the practice, and staff would submit a request on their behalf onto the system. Leaders told us this ensured equity of access as 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. GP leaders had to close the system to new appointment requests to ensure requests which had been received could be responded to and managed safely. However, if people had an urgent need they were still able to contact the practice by telephone. Some options were available for people to use all the time, for example, appointment cancellation, requests for repeat medicines, nurse and health care assistant appointments for cervical screening, blood pressure checks and injections, sick note requests and annual review appointment booking, when an invite had been received.

Leaders had engaged with commissioners, their PPG and people using the service when improvements to access were being considered, implemented and evaluated. The practice had systems to review and understand their telephone and online access system data. The leadership team met monthly to review demand and capacity and had made improvements in response to this. Examples included amending the working hours of care navigators to match the times of highest patient demand, making the telephone message shorter to reduce the number of abandoned calls and promoting the use of the call back service, when people had chosen not to use it. There was an information board at one site which showed current data, for example, the number of people awaiting a call back and time in the queue. The practice had introduced a quarterly patient newsletter in March 2024. This provided updates on access data, for example, the number of inbound calls, virtual call backs, average queue times, completed appointments and appointments where people did not attend. Staff offered people the option of enhanced access clinic appointments. These were available at Chesterfield Drive on Tuesdays and Wednesdays from 7.30am with a nurse, health care assistant and pharmacist. Telephone consultations were available from 6.30pm to 9pm on a Monday evening with a GP. Appointments were available at Norwich Road 1 in every 3 Saturdays with a range of clinicians, including a GP Partner. The Access and Digital Care Co-ordinator role was introduced 2 years ago to proactively support people and staff with digital healthcare technology. This included directly working with people, to support them to use the online access system. Data from 15 July to 4 November 2024, which covered 15 full working weeks showed an average of 7 face to face contacts and 35 telephone contacts with people per week.

We received no specific feedback from people regarding their experiences for this quality statement. Care home representatives told us people received weekly visits with continuity of staff which had improved outcomes for people.

Staff told us they respected and appreciated people's backgrounds and cultural values, and they had received training in equality and diversity. Leaders and staff sought ways to address any barriers to improving people’s experience and outcomes. For example, there was a GP lead and practice champion for domestic abuse who provided support and completed risk assessments and referrals to other agencies. They also supported staff by providing advice and training around domestic abuse issues. The practice also had a learning disability champion who gave additional support and made adjustments to promote equity in people’s experiences and outcomes.

Practice leaders knew the demographics of their patient population in the specific areas covered by the 3 sites. This included for example, age, diversity, disability, deprivation and economic factors which impacted the health needs of their population. People were able to register at the practice by completing a form available at each site or by registering online. Arrangements were in place to support homeless people and temporary residents to register. The practice had employed an Access and Digital Care Co-ordinator who supported people through the registration process, particularly those with communication difficulties. Arrangements were in place for care coordinators to engage with people who are more likely to experience inequalities in health and outcomes. This was usually by telephone with escalation arrangements to a GP if repeated contact attempts were unsuccessful. The practice complied with legal equality and human rights requirements, which included avoiding discrimination and having regard for the needs of people with different protected characteristics. The practice had information available in alternative formats and equipment in place to support people who had a hearing impairment.

We received no specific feedback from people regarding their experiences for this quality statement. Care home representatives were generally satisfied with the support from the practice in supporting people to plan for their future and in meeting their current end of life care needs.

Staff told us they attended regular multidisciplinary (MDT) team meetings where people who were palliative and those receiving end of life care were discussed and reviewed. Staff gave examples of how they supported people at end of life, which included people who lived in a care home. They ensured ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) were completed and up to date, and ensured anticipatory medicines were issued in a timely manner.

The practice had systems in place to support people with palliative care needs and people at the end of their life. There was a multi-disciplinary approach to meetings where people were discussed and reviewed with actions documented, implemented and followed up. The practice 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. We reviewed the records of 3 people, which included 1 person who had a DNACPR decision in place and 2 people who had a ReSPECT (Recommended Summary Plan for Emergency Care and Treatment). These had been completed appropriately following national guidelines. There was a process in place to ensure these were reviewed when the person’s condition, circumstances or wishes changed.