The Care Quality Commission
  • Doctor
  • GP practice

Pembroke Surgery

Overall: Good read more about inspection ratings

31 Alexandra Road, Reading, Berkshire, RG1 5PG (0118) 935 2121

Provided and run by:
Camillus Health Care ltd

All Inspections

During an assessment under our new approach

Date of assessment: 18 March 2025 Pembroke Surgery is a 2 site GP practice in Reading, Berkshire and delivers services to 6,900 patients under a contract held with NHS England within Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board (ICB). Patients can access services from both sites, Pembroke Surgery (referred to as the main practice) and Eldon Square (referred to as the branch practice). The National General Practice Profiles states that the age profile of the practice population largely follows local and national averages with the exception of a significantly higher proportion of patients aged between 25 and 39 when compared to the local and national average. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 8th decile (8 of 10). The lower the decile, the more deprived the practice population is relative to others. We, the Care Quality Commission (CQC) carried out this inspection in response to concerns we received about the service. The last inspection was completed in March 2016 and the practice had a Good overall rating. At this inspection we reviewed 6 quality statements as part of safe and well-led key questions and have combined the scores for these areas with scores from the last inspection (March 2016). The overall rating following this inspection is ‘Good’. Staff understood and managed risks to maintain a safe environment for staff, patients and visitors. The facilities and equipment met the needs of people, were clean and well-maintained and had any risks mitigated. There were enough staff with the right skills, qualifications and experience.

9 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pembroke Surgery on the 9 March 2016. Overall the practice is rated as good. The practice was rated as good for the provision of safe, effective, caring, responsive and well led services.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day. However, some patients reported having to wait sometime to see their preferred GP.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

We saw one area of outstanding practice:

A GP in the practice had received training in ultrasound scanning and provided this service to patients of the practice. The service supported patients who were pregnant with routine and non-routine scans and assisted with the diagnosis of abdominal conditions such as gallstones. The GP worked closely with specialists and consultants at the local hospital and was able to seek advice, as required. This offered an improved service and experience for patients of the practice with a reduction in referrals and admissions, more rapid diagnosis and increased scans for pregnant women offering reassurance with early pregnancy concerns.

The areas where the provider should make improvement are:

  • Ensure the system for monitoring training is more robust and implement a more consistent approach to the recording of training documentation and dates.

  • Consider a review of the PPG virtual group and how this could be further developed to ensure enhanced engagement and involvement with the practice.

  • Review the cervical screening and breast cancer screening to increase uptake to nearer the national average.

  • Clearly display comments and compliments forms in reception.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice