Cambrian 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 Good. At this assessment, the rating remains the same.

This service scored 71 (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 supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The practice had access to interpreter services, and information was available on the website in a range of different languages. Information provided by the service met the Accessible Information Standard. Patients were informed as to how to access their care records.

Within the practice waiting area, we observed a hearing loop facility was available for patients with hearing impairments and a range of health and wellbeing leaflets and posters were on display for patient information.

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. For example, the practice was part of a Primary Care Network (PCN), which offered extended access and access to a range professionals including Paramedics, Pharmacist and Pharmacy Technicians, Cancer Care Coordinator, Care Home Coordinator, First Contact Physio and Mental Health Practitioner.

The practice also worked with colleagues from the local hospices and the district nursing team. Regular meetings were held to review the needs of people who were approaching the end of their lives.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The practice had access to interpreter services, and information was available on the website in a range of different languages. Information provided by the service met the Accessible Information Standard. Patients were informed as to how to access their care records.

Within the practice waiting area, we observed a hearing loop facility was available for patients with hearing impairments and a range of health and wellbeing leaflets and posters were on display for patient information.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. A complaint leaflet included information on how to make a complaint. However, details contained within the leaflet needed correcting and updating. Following our site visit the practice sent us an updated version of the leaflet. A member of the PPG confirmed that the practice encouraged feedback from patients and the practice did its best to resolve any issues raised.

We checked the way the practice managed complaints. We saw complaints were managed in line with the practice’s policy. Complaints had been recorded and acknowledged in a timely manner and thoroughly investigated. An apology was offered and details of how to escalate a concern should the patient not be satisfied with the outcome was noted within the response letter. Learning from complaints was evident and staff were able to identify changes made as a result of patient feedback, including complaints.

Patients were able to book appointments over the telephone, online and in person. We checked the practice’s appointment system and found the next pre-bookable routine appointment with a GP was within 4 weeks of the site visit. In response to patient feedback, the practice had reviewed their system and planned on introducing total triage shortly after our site visit. We saw evidence that the practice had involved the PPG in their planning. The upcoming total triage model was seen by staff as a welcome step to ease pressure and improve patient access, though they acknowledged that successful implementation would require continued support and adaptation.

As part of our assessment, we asked patients to ‘Give Feedback On Care’. We received feedback from 19 patients. The feedback that we received was mixed. Feedback from 9 patients was positive, feedback from 2 patients was mixed and 8 negative. The vast majority of negative feedback related to access to the service with reports of busy lines, disconnections, and difficulty booking at peak times. The telephone system offered a call back service to provide a better service for patients and professionals to avoid people waiting a long time for their call to be answered.

However, the practice scored positively in the National GP Patient Survey 2025 regarding access to care and treatment. For example, 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 respondents reported that they found it easy to contact the practice using the NHS App. Telephone access scored just below the national average with 51% of respondents findings it 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%.

The practice was a ‘Safe Surgery’, which meant that they were committed to providing equal access to their services for everyone in their practice area, regardless of their immigration status.

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

As part of our ‘Give Feedback on Care’ process for this assessment, CQC received one complaint regarding the care and treatment of a patient with additional needs.

Staff treated people equally and without discrimination. Leaders proactively sought ways to address any barriers to improving people’s experience and worked with local organisations, including within the voluntary sector, to address any local health inequalities. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience 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. 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. Multi agency meetings were held with local hospice and district nurses to discuss and note patients’ wishes, including preferred place of death.

Care plans were in place for patients living in a care home.

Our records review showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. This information was shared with other services when necessary. However, Recommended Summary Plans for Emergency Care and Treatment (ReSPECT) forms were not readily available on all patients’ files we checked during the site visit. Steps had since been taken to review this.