- GP practice
Pembroke House Surgery
Assessment report published 31 December 2025
Contents
Ratings
Our view of the service
Date of Assessment: 3 October to 17 October 2025. Pembroke House Surgery is a GP practice that delivers service to approximately 25,500 people under a contract held with NHS England. The service had a branch site named Parkhill Surgery. The National General Practice Profiles states that 96.3% are White, 1.5% are Asian, 1.4% are mixed and 0.8% are of other ethnicities. The service has a higher proportion of older people compared with the national distribution. Information published by the Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 5th decile (5 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.
We assessed all quality statements across the safe, effective, caring, responsive and well-led key questions. At this assessment, we found the service understood their patient population and were passionate about providing safe and effective care. The service worked collaboratively with partners to deliver the best possible care. The service had a strong focus on continuous learning, innovation and improvement across the organisation. Although we identified gaps in recruitment practice, training monitoring and findings from remote clinical searches, the service immediately developed action plans to address them. However, the processes needed time to be embedded into the system.
People's experience of this service
Based on the National GP Patient Survey (GPPS), the NHS Friends and Family Test and feedback directly received by CQC, most people were positive about the quality of their care and treatment once they got an appointment. However, responses from the GPPS showed that 2 indicators related to access were below national averages. The service was aware of the findings and took actions to improve access and people’s experience. There was an active patient participation group (PPG) that represented the views of people using the service. Representatives from the PPG described how they worked collaboratively with the service to collect people’s feedback and empower them to develop their digital skills in submitting medical requests through NHS app training, as well as developing help sheets on using the online system.