Alum Rock 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

We carried out an announced assessment of 7 quality statements (Person-centred Care; Care provision, integration and continuity; Providing Information; Listening to and involving people; Equity in access, Equity in experiences and outcomes and Planning for the future), under the key question Responsive and found:

Since taking over the practice, leaders had acted to improve access. Leaders were aware of the challenges their patient population faced and tried to design services to make them accessible and timely for all people.

Patient feedback was mixed however, it indicated that care, support and treatment was not always easily accessible. People could not always access care in a timely manner and in ways that met their needs.

People and those who supported them could not always easily access information. There was some evidence of partnership working to meet the diverse needs of the local communities.

Leaders collected patient feedback and reviewed published data, however the provider could not demonstrate they had acted on it to deliver improvements.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patient feedback was mixed.

From patient feedback we viewed from a range of sources, including from complaints to CQC, we found patients did not always receive care and support that was co-ordinated or that everyone worked well with the patient. Patients were not always in control of planning their care and support.

Results from the 2024 National GP patient survey were more positive and showed, of those people that responded:

• 73% knew what the next step would be after contacting their GP practice (local average 76%, National average 83%).

• 98% knew what the next step would be within two days of contacting their GP practice (local average 93%, national average of 93%).

Staff discussed learning from complaints in practice meetings.

Staff told us they worked with external organisations to ensure that care was coordinated and patient centred.

Staff discussed palliative care patients in practice meetings.

People received care and treatment that considered their diverse health and social care needs.

The practice had a diverse workforce. This helped staff to understand patients’ needs better and deliver more effective and responsive care.

The practice used long-term locum GPs and had a locum practice nurse. Leaders told us the workforce was stable and this ensured better continuity of care.

Feedback from the primary care network (PCN) showed that the practice made good use of the extended hours appointments that were available to them. They told us that patients could access appointments with the nurse and GP.

Patients could access extended opening hours on an evening and weekend. Leaders received information relating to these appointments, for example if patients did not attend these appointments or if further appointments at the practice were needed.

Leaders collected patient feedback, however, could not demonstrate how they used this information to make further improvements.

Appointments were triaged by the duty GP who then allocated appointments with the correct clinician and ensured continuity of care where possible.

The nurse worked one day a week, this limited patient choice for cervical screening tests, travel vaccinations and childhood immunisation appointments.

Although the practice employed male healthcare assistants and physician associates, salaried GPs who provided daily GP clinics were all female.

We received complaints about the practice not keeping patients informed about changes or about delays when clinicians were running late.

People also commented that staff were not always helpful in providing information.

Leaders told us the practice website was being updated. We saw evidence that showed the provider had been working with an external organisation to improve the website.

Translation services were available in the practice.

The practice website was being updated at the time of the assessment. The current website contained out-dated information. For example, staffing details were not correct, the practice booklet had not been updated and the link to the Friends and Family Test did not work.

We saw there was information about the practice on the notice boards in the waiting areas, for example the complaints procedure, chaperone process, patient participation groups (PPG) information and safe surgery scheme. There was information about health promotion and/or support groups. However, all information except for information about the 111 service was in English and not available in an alternative format.



There was a self check-in screen with different languages available.

There was a television screen with various health promotion messages in English. Patients were called for appointments on screen and by announcement.

Feedback that CQC received was negative about people’s experience when they complained to the practice.

We saw that the practice did not respond to feedback on NHS or Healthwatch websites.

Data from the 2024 National GP patient surgery showed that of those people that responded to the survey:

• 87% were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. This was similar to local and national averages.

• 76% said the healthcare professional they saw or spoke to was good at listening to them during their last general practice appointment (local average 83%, national average 87%).

Representatives from the patient participation group that we spoke to told us they were aware of the results of the national GP patient survey and that satisfaction was below local and national averages. They were consulted for their opinions when changes were made at the practice however, they were not informed about trends in complaints the practice had received and any significant learning or improvements.

All staff we spoke with were able to share examples of complaints that the practice had received.

Leaders told us they were aware that the website required improvement and that satisfaction with access in general was low. They told us they had implemented the duty doctor system to help improve access and that the website was in the process of being improved.

Feedback from staff and leaders was limited about action taken following complaints/patient feedback to improve the service further.

We reviewed the practice’s processes for receiving, investigating and managing information related to complaints. We reviewed 2 complaints in detail and found the process to be satisfactory.

There were processes in place to share learning from complaints with staff.

We found people had different options to provide feedback. This included through NHS and Healthwatch websites, through the complaints process, through the NHS Friends and Family Test (FFT), the practice in-house survey and the national patient survey. Patients could also contact the patient participation group (PPG) and there was a suggestions box. However, all surveys were in English. Throughout the assessment staff told us that many patients did not speak English and required information in a different language.

The practice did not monitor patient feedback that was left on NHS or Healthwatch websites.

The provider had not formed an action plan to improve patient satisfaction following the national and in-house patient survey nor did they provide evidence of how they used FFT data to drive improvement.

We found that individual complaints and incidents were discussed in practice meetings. However, leaders could not demonstrate they had processes in place to review trends and monitor if performance had improved compared with the previous year and what further actions were needed.

The practice had an active PPG who had supported the practice in implementing improvements. From meeting minutes we viewed we saw that PPG members had opportunities to raise questions and they received a response from practice staff.

Data from a range of sources including the 2024 National GP patient survey, feedback on the Healthwatch website and feedback to CQC showed that patient feedback was mostly negative about accessing the service.

Data from the 2024 National GP patient survey showed that of those people that responded:

• 22% found it easy to get through to this GP practice by phone. This was lower than local (40%) and National (50%) averages.

• 24% found it easy to contact this GP practice using their website. This was lower than local (38%) and National (48%) averages.

Data from the August 2024 in-house patient survey showed that 29 out of 40 patients reported a good overall experience of making an appointment, 9 out of 40 patients reported it was very easy to contact the practice by phone and 8 out of 40 patients said it was not easy at all.

From patient feedback CQC had received, patients had complained about not receiving the advice and treatment needed because they had been given an appointment with the incorrect clinician or they were not provided an appointment that met their needs, for example they were not offered a telephone or home visit when it was needed.

Patients complained about long waiting times and not being kept informed about delays.

Leaders told us of the actions they had taken to improve access for patients. For example, introducing a duty doctor system. The practice were also in the process of updating their website.

Staff had access to telephone call data which they reviewed weekly. This meant they could review capacity and demand more effectively and they could amend capacity over the week to deal with busier periods.

Leaders told us that on average 90% of calls were now being answered and this had improved from 75%.

All appointments were face to face unless requested to be telephone.

The nurse worked one day a week and although patients could book an appointment with a nurse through primary care network arrangements (PCN) on evenings and weekends, these appointments were not for cervical screening or for immunisations.

We reviewed the appointment system and found there was good availability of appointments.

Patients could access appointments either at the practice or through extended access between 8am - 8pm Monday to Friday and 9am-5pm on a Saturday. Patients could make an appointment by phone, through the text message system or in person.

However, there were not effective systems in place to reduce inequalities.

We saw there was a large waiting area with sufficient seating. However, seats did not have arm rests to aid people with limited mobility getting in and out of chairs.

There was a hearing loop and access to interpreters.

There was an accessible toilet and baby changing facilities on the ground floor and there was a private area for breast feeding mothers to use. However, the alarm cord in the disabled toilet was not accessible.

The practice had carried out an assessment in 2017 to assess if all patients could access services. The risk assessment had not been reviewed since.

Leaders and staff were not alert to all discrimination and inequality that could disadvantage different groups of people in accessing care, treatment and support.

Leaders had reviewed their processes around appointments and provided training to all staff on how to support patients with additional needs and those requiring reasonable adjustments including autistic patients and people with a learning disability. Feedback from the PCN included that they were in the process of organising appropriate training for non-clinical staff members, however there was no completion date.

There was little evidence of reasonable adjustments within people’s records to help them access the service (other than needing an interpreter), staff were also not able to describe what reasonable adjustments were in place for people.

The nurse worked one day a week, this limited the choice of appointments for people requiring immunisations or cervical screening tests.

We did not collect information form patients to score this evidence category.

From information we viewed including patient records we reviewed, we did not find any evidence to indicate that people were discriminated against. However, because records were not coded correctly with safeguarding information, the provider could not demonstrate all vulnerable patients were receiving the care and treatment they needed in a way that met their needs.

Staff told us all patients had a named GP.

When we spoke with staff there was little awareness of other reasonable adjustments that might be needed to improve people’s experiences and outcomes.

The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and Travellers.

The practice was a Safe Surgery. They offered a welcoming space for everyone who sought to use their services. They ensured that a lack of identification, proof of address, or immigration status would not prevent patient registration.

We saw evidence of some alerts that had been added to patient records to alert staff that patients may need an interpreter. We did not see any alerts indicating that patients may have complex needs, may need an appointment with a particular GP/staff member, may require a longer appointment or that patients might need other adjustments.

We found records were not coded correctly for example with safeguarding information. This meant that vulnerable people’s needs were not always being fully considered to achieve equity in experience and outcomes.

There was limited evidence that leaders considered the needs of people with different protected characteristics and made reasonable adjustments to support equity in experience and outcomes.

We saw that all in-house patient surveys/feedback was done in English and we did not find any examples that showed that the views of vulnerable people had been sought to try to improve their experience and outcomes.

We did not collect patient experience information that related to planning for the future. However, evidence we reviewed did raise concerns about DNACPR forms not being reviewed regularly including when people changed care setting and safeguarding registers were not complete or regularly updated.

Staff kept a palliative care register and told us patients were reviewed according to their needs and discussed during practice meetings. The practice had processes in place to review if care and preferences had been met in line with patients wishes.

Staff told us patients had personalised care plans that included decisions that were guided by information about what mattered to them.

Our records review indicated that people with long term conditions were reviewed and involved in decisions about their care and future planning where appropriate. However, we found with more complex or vulnerable patients, the practice could not always demonstrate this.

Although the practice had a lead for palliative care we did not see evidence of regular palliative care meetings where registers where updated.

The practice did not have regular safeguarding meetings or registers that were complete or up to date.

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions had not been reviewed by the practice when people were discharged from hospital. Staff showed a lack of understanding of why this was needed.