Pembroke House 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 assessed all quality statements in the responsive key question.

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same. The service met people’s needs, and staff treated people equally and without discrimination. Requests for appointments were allocated based on clinical needs. The service understood their patient population. They identified and made changes to improve their service where required.

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.

Our review of clinical records showed people were supported to understand their condition and were involved in planning for their care needs. They were also involved in decisions about their care. Staff treated people as individuals and with respect. They also provided longer appointments for people who needed them.

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.

The service worked in partnership with other services to meet the needs of its population. This was evidenced by people’s positive feedback mentioning how the service organised assessments, tests and hospital appointments for them efficiently. The service had tailored its services to meet the diverse needs of its community. For example, the service set up a one-stop health check clinic for people with a learning disability where they received assessment by the learning disability lead, GP and pharmacist in a single longer appointment. A dedicated waiting area was also set up to cater for their needs. We saw examples of people who had accessed services through the social prescriber including areas such as bereavement support, weight management support, and social activities and had received a variety of positive outcomes in terms of their wellbeing. People shared that they were listened to without judgment and found new friends through the social support group. They received food parcels which were much needed. The social prescriber helped them overcome fear during GP consultations caused by past experiences. As a result, they were regularly cared for by the service.

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

Staff highlighted any communication or accessibility needs on the electronic clinical records.Interpretation services were available for people who did not speak English as their first language. The service incorporated a digital accessibility tool on their website to enhance accessibility and improve people’s experience. The service’s website contained a variety of information to support and educate people, includingself-help advice on healthy lifestyles and mental wellbeing.

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.

People could raise concerns by speaking to the service, in writing or through the online form on their website. The service had a policy and procedure to support and guide staff dealing with complaints. There was a system to record and investigate complaints. People who raised concerns were listened to and a response was provided. When things went wrong, staff apologised and gave people support. We saw evidence complaints were managed efficiently and were used to drive continuous improvement. The service held regular meetings to review complaints and share the lessons learned and actions taken with staff. The service regularly collected people’s feedback through the NHS Friends and Family Test. Staff shared an example of how the prescription process was reviewed following people’s feedback to ensure the prescriptions were sent to the people’s nominated pharmacies.

The service was exceptional at ensuring people could access the care, support and treatment they needed when they needed it.

People could access appointments online, over the telephone and in person. Reception staff helped people to fill in medical request forms if they were unable to do so. People could use the electronic device at reception to complete the medical request form. The service used a ‘total triage’ model, in which people were triaged by clinicians based on clinical needs and urgency. All medical requests, regardless of how they are received, were processed through the same triage process. People were either offered a same-day or routine appointment or directed to the appropriate services. We reviewed the appointment diary and saw appointments were available to book the same day for urgent appointments. The service provided unverified data from the local ICB which showed 59% of people were seen on the same day, 67% of people were seen within 1 day of request and 90% of people were seen within 2 weeks which were all above national averages. The number of available appointments per patients per month was also above the local average.

Some people told us they found contacting the service difficult, especially because the online consultation form was open only for a short duration each day and appointments were taken quickly. The service turned on the online consultation platform during core service hours since 1 October 2025 due to the contractual requirement for all NHS GP services. The service demonstrated how it coped with the subsequent rise in medical requests to ensure safe care. However, it was still too early to determine whether people's experience had improved. The 2025 National GP Patient Survey data showed the percentages of people who responded positively to the overall experience of contacting the service was 61% (national average of 70%) and people who responded positively to the ease of contacting the service by phone was 27% (national average of 53%), which were both below the national averages. The service took actions to address these. For example, the service provided additional training to reception staff to improve communication skills. The service encouraged people to use digital access by empowering them with training and help guide to use the online platform and NHS app. This helped to reduce demand on telephone lines and thus improved access for those facing digital barriers.

The service recognised people’s feedback about the long wait for routine appointments. The service took actions to address this by increasing GP capacity through recruitment, ongoing review of the balance between urgent and routine appointments, monitoring the triage data to meet the demands and the use of clinicians other than GPs as appropriate to increase appointment availability.

The service hosted and led the enhanced access (EA) project in Torbay and South Devon to promote equity in access. The service employed staff to provide appointments in the evenings, weekends and bank holidays so that people could access primary care 7 days a week. The EA service had been running continuously for 7 years with adaptation to national and local changes during the period.

The service had lifts to upper floors and consultation could be arranged on the ground floor if needed. The service was equipped with a hearing loop for people with hearing impairment.

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.

Feedback provided by people using the service, both to the provider as well as to CQC, was positive. The provider had processes to ensure people could register at the service, including those in vulnerable circumstances such as homeless people. Interpretation services were available for people who did not speak English as their first language. The service was flexible in its approach to supporting people. For example, home visits could be arranged if required, and the service could provide flu vaccines while the people stayed in their cars if they had mobility issues. The service used appropriate systems to capture and review feedback from people using the service, including those who did not 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 lives.

Our do not attempt cardiopulmonary resuscitation (DNACPR) records review showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. Care plans documented a DNACPR decision when it had been made. This information was shared with other services when necessary. The service discussed people on palliative care in monthly multi-disciplinary team meetings to optimise their care.