The Penrhyn Surgery

We carried out an announced inspection at The Penrhyn Surgery on 05/05/2022. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe – Good

Effective – Good

Caring – Good

Responsive – Good

Well-led – Good

Following a new provider registration in 2019, this was the first inspection of the location under the new provider. Following this inspection on 04 May 2022, the practice was rated Good overall and for all key questions.

The full report for this inspection can be found by selecting the ‘all reports’ link for The Penrhyn Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection and included the key questions: safe, effective, caring, responsive and well-led.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A site visit

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall;

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Although the lead GP had reviewed systems and processes, Childhood immunisation uptake rates were below the World Health Organisation (WHO) targets. Uptake rates for the vaccines given were below the target of 95% in five areas where childhood immunisations are measured.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• The practice had not demonstrated it had an effective strategy to improve its performance for cervical screening which was lower than the national average.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• The practice had an active patient participation group.
• There was evidence of systems for learning, continuous improvement and innovation. For example, during the COVID19 pandemic, the practice started a wellbeing gardening project at the practice in conjunction with a local gardening group. Staff worked with external partners and patients to develop and deliver a gardening project to support people experiencing loneliness and social isolation during the pandemic.

Whilst we found no breaches of regulations, the provider should:

• Continue to improve the uptake of cervical cancer screening and childhood immunisations.
• Review monitoring of patients on high risk medicines to ensure all patients have lithium levels checked.
• Review action plans to ensure housebound patients receive required blood pressure monitoring.
• Review coding of patients diagnosed with asthma or COPD and ensure staff document when appropriate medicine review takes place.
• Review systems to ensure scheduled staff appraisals take place when due.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care