- GP practice
Cambrian Surgery
Assessment report published 18 September 2025
Contents
Ratings
Our view of the service
Date of Assessment: 29 May 2025 to 3 June 2025
Cambrian Surgery is a GP practice and delivers service to 13,411 patients under a contract held with NHS England. The National General Practice Profiles states that the patient ethnicity profile is made up of 96.91% White, 1.23% Asian, 0.7% Black,0.7% Mixed and 0.46%. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 6th decile (6 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
SAFE: The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained but not all identified risks had been mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. However, there were a small number of concerns that the Care Quality Commission (CQC) identified in relation to providing safe services. These included the oversight of emergency medicines and the monitoring of people prescribed steroids for the exacerbation of asthma and the management of hypothyroidism. The authorisation of written instructions for administering of medicines also required attention and some minor issues relating to safe recruitment practices were identified. Following our site visit, the provider sent us information confirming the action they had since taken to mitigate risks to ensure people were protected and kept safe.
EFFECTIVE: People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. On the whole, care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Relevant forms were not available on the records of all patients with ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions recorded.
CARING: People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
RESPONSIVE: People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took their feedback seriously and acted on it. Some patients found that the service was not always easy to access. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
The practice scored positively in the National GP Patient Survey regarding access to care and treatment. A total of 64% of respondents found it easy to contact the GP practice using their website, which was higher than the national average of 51%. A higher than national average of patients reported that they found it easy to contact the practice using the NHS App. Telephone access scored just below the national average at 51% of respondents found it was easy to get through to the practice by phone in comparison to national average of 53%. However, only 28% of patients reported they usually get to see or speak to their preferred healthcare professional when they would like to, which was below the national average of 40%
WELL-LED: Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.
People's experience of this service
People were positive about the quality of their care and treatment. Recent survey results, including from the National GP Patient Survey 2025 and the NHS Friends and Family Test (FFT), showed people were satisfied with services. Feedback from patients completing the FFT in 2025 showed over 90% of patients would recommend the practice to friends and family. There was an active patient participation group (PPG) who represented the views of people using the service. Representatives from the PPG described how managers made positive changes following feedback.
The Care Quality Commission (CQC) received 19 completed give feedback on care forms from patients. Nine of these were positive, 2 mixed and 8 were negative. Patient experience at the practice reflected a mix of positive outcomes and areas for improvement. Many patients commended the staff for their compassion, professionalism, and dedication, often going above and beyond to support patients, including those with long-term conditions and additional needs.
Patients told us the telephone consultation system worked well for some, with timely callbacks and efficient face-to-face arrangements when necessary. Communication around chronic health monitoring and test follow-ups was also positively noted by several patients.
However, concerns were shared regarding access to appointments, particularly via phone, with reports of busy lines, disconnections, and difficulty booking at peak times. Feedback on communication was mixed, and feedback received suggested that a small number of patients sometimes experienced barriers to appropriate care. Reception and administrative staff received both positive and negative feedback, with some patients described a friendly service while others reported a dismissive or inflexible service. Overall, the practice was appreciated by many for its dedicated staff and supportive approach, but would benefit from improving appointment access, communication consistency, and care for more complex or vulnerable patients.
Staff described the practice as a friendly, supportive, and well-led workplace with strong teamwork and approachable leadership. They felt valued, appreciated, and committed to delivering high-quality patient care despite rising demand. Regular teaching, open communication, and staff recognition contributed to positive morale and a collaborative culture.
Areas for improvement included introducing clearer pay banding for administrative staff, improving internal communication, and involving all teams more in decision-making. Staff also noted the need for more practice nurses and further development of the nursing team. The upcoming total triage model was seen as a welcome step to ease pressure and improve patient access, though successful implementation would require continued support and adaptation.