Pendeen Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The practice fostered a well-established, inclusive, and positive learning culture that contributed to better outcomes for patients and the wider community. Learning was actively shared with, and drawn from, external partners to support continuous improvement.

Governance and management systems enabled leaders to monitor risks, performance, and outcomes effectively. Leaders continually sought to improve service delivery, using feedback from both staff and patients to reduce risks and enhance the quality of care.

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

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 practice had a clear mission statement of “Working in partnership to provide a caring and quality service.” The practice had an established set of values which included: providing a safe practice for patients and a safe working environment for staff; treating people with compassion, kindness, dignity and respect; and delivering services that are appropriate for the needs of patients.

Staff told us they aimed to provide a modern service whilst keeping a traditional patient-centred approach.

Feedback we received from staff regarding the culture within the practice was very positive. They told us it was a positive and friendly environment to work in, the culture was open, transparent, blame free and non-discriminatory and they enjoyed working there.

Leaders had the skills, knowledge, experience and credibility to lead effectively.

Staff told us that leaders in the practice were approachable and responded to any concerns raised. Leaders showed a strong commitment to staff development, investing both time and financial resources into learning opportunities.

Staff felt leaders modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

Leaders actively engaged with patients, staff, and partner organisations to gather feedback and they took meaningful action in response. They demonstrated during the assessment how they made changes for the better wherever they could.

The practice fostered a positive culture where staff could speak up and their voice would be heard. Staff were confident their concerns would be acted upon. There were also systems in place to support staff to whistleblow or to speak with a ‘Freedom to Speak Up Guardian’ if they needed to. The practice had appointed a primary care network manager who was external to the practice to the role of the Freedom to Speak Up Guardian.

The practice valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who work for them. Policies and procedures to promote diversity and equality were in place. Staff had received training in equality, diversity and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion and disability. There was a zero tolerance to bullying and harassment and leaders were committed to providing an inclusive and supportive working environment.

All staff we either spoke with or received questionnaires from, reported high levels of job satisfaction. They told us they felt valued and were encouraged to be involved in contributing to the running of the practice. A number of staff had longstanding employment with the practice.

The practice had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff to complete appraisals and performance reviews.

The practice had established governance processes and staff could access all required policies and procedures. Managers held regular meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for patients. They shared information and learning with partners and collaborated for improvement. Staff were encouraged and supported to attend local forums which provided networking opportunities with other services within the primary care network. The practice worked with other practices within their primary care network (PCN) to offer extended access appointments for patients.

The practice had an active patient participation group (PPG) which was supportive of the practice in driving improvements. The PPG acted as a conduit for communication between the local community and the practice. We spoke with a member of the PPG who gave positive feedback about the practice and improvements which had been made.

The PPG met monthly as a working group and quarterly as a larger group. Staff told us the PPG had helped the practice with several projects in the last 12 months including successfully lobbying the local council to improve signage in the practice car park. Following a change to the one way system, staff were very worried that a patient may experience a serious car accident. The PPG also suggested that the practice put up additional signage which the practice funded and implemented for the safety of patients.

In addition, staff told us the PPG assisted the practice by proof-reading all of the standard letters and text messages to ensure they are easy to read and understand for patients. This was initiated as a result of feedback from patients who informed the practice they experienced difficulties understanding medical jargon.

The practice had a strong focus on continuous learning, innovation and improvement. Leaders encouraged staff to put forward and test out new ways of working. Staff were given opportunities for learning and career development.

Staff participated in quality improvement work and used learning from significant events and complaints to continually improve the service they provided.

Since our last inspection, the practice had become a GP training practice and there were 4 GP trainers. Staff told us having 4 GP trainers has enabled them to take on more GP trainees and GP trainees had regular tutorials and supervised one to one contact.

The practice were due to participate in two pilots for the local primary care network. Staff told us the first pilot was a continuity tool to facilitate identifying patients that would most benefit from seeing or speaking with the same clinician such as palliative care patients, patients with cancer, and patients with complex health and mental health needs. Staff explained the trial would be for 3 months following which the practice will report back to the PCN and it will be used across the PCN to help improve continuity for patients.

The second pilot staff told us about was a Community Geriatric Assessment (CGA). One of the GP partners was the frailty lead for the PCN and told us they had been working with the Integrated Care Board on updating the CGA. Staff told us they were piloting the CGA in the practice before it is rolled out to other practices in Herefordshire.

Staff told us other future improvements to the service included ‘Saturday Clinics’ at the practice for talks on menopause, wellness and healthy lifestyles for farm workers registered as patients with the practice.

In addition, staff told us they had made a successful bid for Estates Utilisation and Modernisation Fund (UMF). This bid will enable the practice to make changes to the administrative rooms to allow more workspace upstairs in the building.