Pendeen 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

People were involved in decisions about their care. The practice provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it.

The service was easy to access. Direct feedback to CQC highlighted patients found it easy to make appointments. Results from the National GP Patient Survey also highlighted that patients could easily access the practice. Patients received fair and equal care and treatment. The practice worked to reduce health and care inequalities through training and feedback.

At our last assessment, we rated this key question as Good. At this assessment, we rated the key question as Outstanding.

This service scored 89 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice endeavoured to make sure patients were at the centre of their treatment choices.

Care plans reflected physical, mental, emotional, and social needs of patients including those related to protected characteristics under the Equality Act. Our review of clinical records showed patients were supported to understand their condition and were involved in planning for their care needs. They were also involved in decisions about their care.

The National GP Patient Survey found 96% of patientshad confidence and trust in the healthcare professional they saw or spoke to during their last general practice appointment. We also reviewed six months of data from the NHS ‘Friends and Family Test and found the vast majority of feedback was rated as either ‘Good’ or ‘Very Good.’

The practice understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

As part of this assessment, we reviewed the practice’s clinical system and saw that referrals to other services were made promptly and information shared by other services was managed effectively and timely to support good outcomes for people.

The practice worked closely with their Primary Care Network (PCN) and helped to plan, develop and deliver services across the locality with a view to improving patient satisfaction. For example, the practice surveyed patients and found they would prefer extended access appointments with a GP they knew at their own practice if possible. Working with the PCN, the practice commenced providing patients with extended access appointments in-house this year and this has been positive for patients in providing continuity of care and reducing travel to other surgeries.

The practice supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. The practice provided patients with information in a variety of methods including a practice newsletter, the website and the text messaging service. We observed the practice waiting area had a range of health and wellbeing leaflets and posters on display for patients.

The practice had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard. Patients were informed as to how to access their care records.

Results from the National GP Patient Survey showed that 91% of patients knew what the next step would be after contacting their GP practice. This was above both the local and national averages. In addition, 93%of patients felt the healthcare professional they saw had all the information they needed about them during their last general practice appointment.

The practice operated a fully computerised pathology lab system and staff utilised ‘Healthshare’ software to access hospital data. Leaders told us they had upgraded the practice website, and a bi-monthly newsletter was produced for patients with a range of health information.

The practice had collaborated with the headteacher of a local sixth form college to provide information for students regarding careers in medicine. The practice made arrangements for one of the GPs to attend the college for a morning to give a presentation to students. The presentation included why she chose a career in medicine and a role as a GP; what a typical working day and week looked like and information about post-university training. As part of this initiative, the practice offered work placements for students who were considering a career in medicine.

Patients 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.

Our records review showed patients were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. This information was shared with other services when necessary.

The practice held registers for a number of different patient groups, this included those with learning disabilities, mental health problems and also those on end-of-life care. They were regularly reviewed and updated to ensure these patients were supported.

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

Results from the National GP Patient Survey were extremely positive in regard to contacting and accessing the surgery:

76% of patients found it easy to get through to this GP practice by phone, this was significantly above the local average of 61% and national average of 53%.

72% of patients found it easy to contact this GP practice using their website which was also above the local average of 59% and national average of 41%.

72% of patients found it easy to contact this practice using the NHS App, again this was above local average of 58% and national average of 49%.

82% of patients were offered a choice of time or day when they last tried to make a general practice appointment. This was well above the local average of 58% and national average of 54% results.

87% of patients described their experience of contacting their GP practice as ‘Good’ which was above the local average of 77% and national average of 70%.

Patients were able to book appointments over the telephone, in person and online. The practice had reviewed capacity and demand to identify how many on-the-day appointments were needed in relation to pre-bookable appointments and built the rotas accordingly. Staff explained there was a four-week rota so GPs could book their own follow up appointments before a patient appointment finishes. Staff said this was crucial for continuity of care and patients found this very reassuring and convenient for them.

Patients were offered an appointment appropriate for their assessed need or directed to an alternative service, for example, a pharmacist or social prescriber. Patients were also signposted to the local urgent care centre when appropriate.

During our assessment, we looked at the practice’s appointment system and could see that patients were able to book appointments that suited their individual needs. We saw that there were still appointments available that day for patients.

Concerned parents were encouraged to contact the practice for GP advice for their unwell child. GPs triaged the problem to determine the urgency of need and offer guidance, support, or a face-to-face appointment regardless of the appointment capacity.

‘Extended Access’ appointments were also available for patients within the practice, outside of the core hours. Leaders explained that extended access appointments were previously provided by the GP Federation and patients were having to travel to other places and practices for these appointments. The practice surveyed their patients and found patients would prefer appointments with a GP they knew at their own practice. In response to this feedback, the practice started offering their own extended access appointments this year. Staff told us these extended access appointments were very popular with their patients and had improved their continuity of care.

Patients living in a care home, received a ward round on a weekly basis from a GP. Housebound patients were offered appointments with GPs and the primary care practitioner.

Leaders regularly monitored, audited and evaluated access to appointments. The practice had upgraded their telephony system to incorporate call back, digital messaging, online booking and triage functions.

Staff had worked to improve access to the service by promoting the usage of the NHS App. The practice had 3 members of staff who are NHS App ambassadors that champion the NHS App and provide guidance and support for patients. The practice also worked with the PPG to identify patients who did not have the NHS App and would like help setting it up during a ‘PPG Awareness Week’ which was organised in the practice. A self-help QR code poster had also been displayed in the practice to assist patients with the NHS App.

Staff told us the NHS App usage had significantly increased with 3000 patients logging in to the app in January 2024 compared to 8500 patients logging in to the app in June 2025.

As part of the PPG awareness week, over 250 patients were surveyed. Appointments data from this survey showed 31% of patients were seen within 48 hours; 25% within a week; 32% within 2 weeks and 10% waited over 2 weeks.

Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. Staff and leaders were innovative in how they listened to information about people who are most likely to experience inequality in experience or outcomes. Staff and leaders actively used this information to provide exceptionally tailored care, support and treatment in response to this.

For example, the practice had established an excellent rapport with local farms who employed mainly overseas workers seasonally. Staff told us that during the COVID 19 pandemic, practice staff went out to the farms to vaccinate the workers which was approximately 700 people.

To care for their migrant worker patient population, staff explained that for workers already on medications from their previous country or practice, they were registered expediently so there was not a delay in their healthcare. Non-English speaking patients were highlighted on the clinical system that they required a translator which the practice provided and double appointments were booked to allow extra time needed. On an annual basis, the practice met with the farm welfare officer to address any improvements that could be made to the service offered by the practice to the farm employees. In addition, the practice provided the farms including the mobile homes where the farm employees live with health education information such as posters and leaflets on alcohol, smoking and contraception. Staff told us their future plans to improve the care provided for the migrant workers. This included providing Saturday group clinics regarding women’s health, contraception and men’s health and providing translators to inform and educate workers on the healthcare that can be provided for them.

We received feedback from a welfare officer about the practice who told us their farm staff were always taken to Pendeen Surgery to register as patients as they found the registration process was easy; no employees were refused registration; and staff were professional and caring.

We saw the practice worked in partnership with other services to be responsive to the needs of its patient population. For example, we saw the practice had built strong relationships with a local care home and two local learning disability care homes whose residents were registered as patients with the practice.

The care homes were visited weekly by one of the GPs who was the frailty lead for the PCN. If a physical visit was ever not possible, the homes would receive a telephone ward round with the GP. The GP told us these visits have facilitated continuity of care for patients and has reduced the need to access the urgent care team. The GP worked closely with the PCN care home nurse and provided regular mentoring sessions. At the elderly care home, a ‘professional’s lunch’ was held monthly, and a member of the practice attended to have lunch with the staff and residents.

The practice had a primary care practitioner who supported the frailty lead by undertaking visits to vulnerable housebound patients. The primary care practitioner was able to discuss Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms with patients and their families. Staff told us the primary care practitioner was allocated one hour per patient visit but revisited the same patients’ numerous times offering a listening ear to their concerns. Staff explained some of these patients used to be on the urgent call list every week but were now very well supported.

In addition, the primary care practitioner also visited patients who were back home after a prolonged admission to hospital and did a welfare check to see how they were coping. Staff told us this role was not funded or offered by any other GP practice in Herefordshire.

To improve the service offered to patients who were also veterans, the practice had appointed a veteran administrative lead. The lead told us on commencing this role they had undertaken research of various resources available for veterans and had visited a local support centre. Following this visit, a number of changes had been implemented within the practice including identification forms, information packs, notice boards, leaflets, and support questionnaires. The lead also worked alongside social prescribers to help identify the types of support needed by the veterans.

Since January 2024, staff told us there had been an increase of 81% of patients coded as veterans in the practice and feedback from the PCN wellbeing team indicated there had been a 40% increase in the number of referrals from June 2024.

Leaders had proactively sought out ways to address barriers to improve people’s experience within the practice premises. For example, leaders had asked the sensory friendly environment team for Hereford and Worcester to visit the practice and provide advice on how they could become sensory friendly. We observed a designated area set back from the waiting room with a privacy screen which had a sensory box containing emotion fans, and toys. Staff told us this provision had been positively received by patients and gave us an example of how this had positively impacted a child patient who was experiencing sensory overload in the waiting area. In addition, all staff had received Oliver McGowan training to improve the care of autistic people and people with a learning disability.

Staff told us they had also approached all patients with a disability to ask for feedback how the practice could improve the service. In response to patient feedback, the practice installed braille signage at reception and the patient toilet door to assist patients with sight loss and purchased a new hearing loop to assist patients with hearing impairments.

As part of our assessment, we reviewed the results from the National GP Patient Survey which showed that 90% of patients felt their needs were met during their last general practice appointment. This was in line with the local average of 92% and national average of 90%. It also showed that 82% of patients described their overall experience of this GP practice as good, this was in line with the local average of 81% and above the national average of 75% results.

Patients 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.

Our records review showed patients were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. This information was shared with other services when necessary.

The practice held registers for a number of different patient groups, this included those with learning disabilities, mental health problems and also those on end-of-life care. They were regularly reviewed and updated to ensure these patients were supported.