The Care Quality Commission
  • Doctor
  • GP practice

Pendeen Surgery

Overall: Outstanding read more about inspection ratings

Kent Avenue, Ross On Wye, Herefordshire, HR9 5AH (01989) 763535

Provided and run by:
Pendeen Surgery

All Inspections

During an assessment under our new approach

Date of Assessment: 14-17 July 2025. Pendeen Surgery is a GP practice located in Ross on Wye, Herefordshire. Pendeen Surgery delivers services to around 8,900 patients under a contract held with NHS England. The provider is registered with CQC to deliver the following Regulated Activities: Diagnostic and screening procedures; Family planning; Maternity and midwifery services; Treatment of disease, disorder or injury; and Surgical procedures. We inspected and rated this service under our previous methodology in August 2016. The practice was rated Good overall and in all key questions. This assessment was carried out to assess the quality of services being delivered due to the length of time since the previous assessment. The practice has been rated Outstanding overall. The key questions of Safe, Effective, and Well-led have been rated Good. The Responsive and Caring key questions have been rated as Outstanding.

The National General Practice Profiles states that the ethnic make-up of the practice area was 98% White, 0.8% Mixed Ethnicities, 0.5% Asian, 0.4% Black and 0.3% Other Ethnicities. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 7th decile (7 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.

7 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pendeen Surgery on 7 June 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There were robust systems in place to monitor and maintain safety in the practice.
  • Staff understood their responsibilities to raise concerns and to report incidents and near misses. Incidents were viewed as opportunities for learning and improving patient care.
  • The practice was visibly clean and hygienic. There were arrangements for assessing and mitigating the risks from healthcare associated infections.
  • Patients’ needs were assessed and their care was delivered in line with best practice guidance.
  • The practice team was well trained and had skills and experience in a range of health conditions.
  • Feedback from patients about their care was consistently positive. Patients said that GPs listened to them and that they were treated with compassion, dignity and respect. Patients felt that they were involved in their care and decisions about their treatment.
  • The system for recording and learning from significant events was well embedded and robust.
  • The system for undertaking regular audits was robust. The practice routinely presented the findings at the educational meetings to drive improvement in patient care.
  • Information about services and how to complain was available and easy to understand. The practice responded to complaints in an appropriate and timely manner. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients told us that it was easy to make an appointment with a named GP and that there was continuity of care. Urgent appointments were available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had an area set aside for use by children, which contained books and toys.
  • There was a clear leadership structure and staff felt supported by management.
  • The practice proactively sought feedback from staff and patients and used the feedback to improve services to patients.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

We saw two areas of outstanding practice:

  • The practice had proactively engaged with a manager and the welfare officer of a local farm where many seasonal workers from overseas were employed in order to facilitate access to the practice services. This was a practice led initiative which resulted in the seasonal workers being accompanied at appointments by a person who could translate for them.
  • The system in place for managing and monitoring significant events was extremely robust. The summary details were logged on a spreadsheet, which contained hyperlinks to the full discussion and decision process. This system originated in 2005 and had been adopted by other practices.

The area where the provider should make improvement is:

  • Review the arrangements for checking on any uncollected prescriptions.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice