Penshurst Gardens 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 looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination.

At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating has changed. This provider is now rated Good for the key question of Responsive.

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 service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

People who provided feedback to us had no specific views or concerns in this area. The provider 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 surgery had arrangements in place to support person centred care. People were booked into appointments with their named GP for continuity, if this is what they requested. Appointments could be booked online or by telephone on a date and time to suit patients. 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.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

We saw the practice worked in partnership with other services to meet the needs of its patient population. The practice had tailored its services to meet the diverse needs of its community, for example, working with its Patient Participation Group (PPG) to convey the work the practice had undertaken to increase accessibility to services at the practice for all patients. There were established mechanisms for engaging with partner community healthcare providers.

The surgery supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. Patients were informed how to access their care records. The surgery website provided comprehensive information regarding the surgery staff, services available and links to other relevant organisations that patients would find useful. The surgery had access to interpreters and highlighted on patient records if patients had any communication or accessibility needs.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

The surgery had received 20 complaints from July 2024 to the beginning of April 2025. We examined a sample of these complaints and found (from the sample we reviewed) complaints had been managed satisfactorily in a timely manner and were managed in line with the surgery’s policy.

We saw from meeting minutes that complaints were a standing agenda item in clinical and surgery team meetings. Leaders told us that any learning from the management of complaints and patient feedback was embedded within the day-to-day running of the surgery, to prevent any future complaints relating to similar themes.

Although the surgery did not question patients directly about equity in access, most patients who responded to the internal patient survey were satisfied with the overall service.

However, feedback from the National GP Patient Survey (conducted between January and March 2024) indicated that access to the surgery could be challenging and people were not always able to get an appropriate appointment for their care and treatment needs

Staff had access to guidance to support decision making in this area. Staff and leaders explained how they understood the needs of the local population and had developed the service in response. Staff told us they provided opportunities and support for different groups of the patient population to overcome health inequalities.

Since the last CQC inspection/assessment, the surgery had reviewed and developed systems and processes for prioritising people presenting with the highest need to ensure that patients requiring urgent access to clinical care were able to access it.

The service made sure that people could access the care, support and treatment they needed when they needed it. The surgery undertook patient surveys to review the quality of care provided.

Feedback provided by people using the service, both to the provider and to CQC, was varied.

Some people’s experience was positive, however, some people told us they did not feel they got the right support at the right time to meet their needs. Staff treated people equally and without discrimination. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. Leaders spoke with us about how they would identify ways to address any barriers to improving people’s experience and worked to remove those barriers.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff treated people equally and without discrimination. Staff had completed training in equality, diversity, and inclusion. The surgery had processes to ensure people could register at the service, including those in vulnerable circumstances such as homeless people and Travellers. Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to the internet.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

We did not undertake any records review as part of this assessment; however the practice was able to discuss how people were supported to consider their wishes for their end-of-life care, which included having care plans including details relating to having cardiopulmonary resuscitation. This information was shared with other healthcare services when necessary.