The Penrhyn Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same. This meant the service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

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’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Patient experience of the service, as reflected in the 2025 National GP Patient Survey, was slightly lower than local and national averages. Of those who responded, 81% felt involved in decisions about their care and treatment, compared with 88% across the Integrated Care System (ICS) and 91% nationally. 88% of patients reported having confidence and trust in the healthcare professionals treating them, compared with ICS and national averages (90% and 93% respectively). 81% of respondents felt their needs were met during their last general practice appointment compared with ICS average 87% and national average 90%.

We were provided with patient feedback from local Healthwatch which they had gathered in June 2025. Healthwatch staff interviewed patients in person at the service and completed a questionnaire. There were 15 responses. The positive feedback included the quality of treatment and care received. 93% reported feeling listened to, able to ask questions, and involved in decisions. Clinical staff were described as kind, knowledgeable, and competent. People were also positive about the attitude of staff at the service describing staff as polite and caring. The Healthwatch team observed positive interactions between reception staff and patients. There was some mixed feedback about people’s experience of access to appointments through online consultation and the telephone.

Staff had followed prescribing protocols and guidance to ensure assessments were up-to-date and people’s care needs were routinely reviewed. As part of the assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. A sample of the records of patients with long-term health conditions were checked to ensure the required monitoring was taking place. These searches were visible to the service.

There were 321 patients on the asthma register. Our searches identified 3 patients diagnosed with asthma, who had been prescribed 2 or more courses of rescue steroids in the last 12 months. Only 1 patient had rescue steroids prescribed for asthma which suggested that the service was very good at managing and reducing the need for steroid rescue in their asthmatic population.

Clinical searches identified a total of 190 patients prescribed medicines to treat an underactive thyroid gland (hypothyroidism). There were only 2 patients with hypothyroidism who had not had thyroid function test TFT monitoring in the last 18 months. We reviewed the records of these 2 patients and found no concerns.

Patients at risk of diabetic retinopathy had received the appropriate management and monitoring. The number of patients on the diabetes register was 373. Our clinical searches identified a total of 64 patients with diabetes who’s latest HbA1c was >75mmol/l. We reviewed 4 patients and found 2 patients with high HbA1c who required further review of their diabetes medicines. There was evidence the service had contacted these patients to invite them in for review. Following our inspection, leaders told us they had reviewed the patients with high HbA1c to see if anything further could be done to encourage people to attend for review.

A search identified 2 patients with chronic kidney disease, CKD Stage 4 or 5, who appeared not to have had necessary monitoring in the last 9 months. After review of these 2 patients only 1 was a slight concern which the provider took immediate action to follow up.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present.

People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. Staff described the processes they used to invite patients in for their reviews and action they took if patients did not attend. The provider had effective systems to identify people with potentially undiagnosed conditions such as cancer or diabetes.

The service planned and delivered people’s care and treatment with them, including what was important and what mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Systems were in place to ensure staff were up to date with guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance. Staff carried out annual reviews for people with long-term conditions.

We reviewed a sample of learning disability and mental health patients’ annual care plans and found they were satisfactory.

The service worked well across teams and services to support people. Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The service worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. There were systems in place to support the effective assessment and treatment of patients with more complex needs. Clinicians attended monthly Integrated care meetings to discuss patients with complex needs.

In November 2024, the Penrhyn Surgery took part in the Winter Wellness event at South Chingford Community Library, a collaborative initiative to tackle local health inequalities. The event offered health awareness information and preventive care, including Covid-19 and flu vaccinations, blood pressure checks, and bowel cancer screening sign-up. A social prescriber and welfare support partners attended, and patient participation group members were encouraged to attend. Leaders told us they plan to offer further events to reduce health inequalities.

Leaders told us the service participated in the local Primary Care Network (PCN), where they collaborated on shared service delivery and quality improvement initiatives.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The service had a PCN care coordinator who contacted patients with complex needs or who were vulnerable to ensure their needs were being met. They would refer patients to the PCN social prescriber and welfare and social organisations. Staff told us patients had access to a community mental health specialist nurse and the service had a GP with special interest in Mental Health.

Data from the 2025 National GP patient survey showed that 65% of people completing the survey felt they received enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses. This was higher than the local average (61%) and lower than the national average (69%). Sixty-three percentsaid the healthcare professional they saw or spoke to was good at considering their mental wellbeing during their last general practice appointment. This was lower than the local (71%) and national (74%) averages.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent. Most people who used the service felt they could make an informed decision about their care and treatment because they had been provided with the information they needed to support them to do so. The National GP Patient Survey results showed that 74% of respondents felt they had all the information they needed and 81% felt involved as much as they wanted to be in decisions about their care and treatment. These results were lower than the local and national averages.

The provider had processes to monitor people’s care and treatment to continuously improve it. There was a system in place to recall patients for long term health condition reviews. The service had signed up to a clinical review service delivered through a national team of pharmacists. Staff told us the new review service helped staff manage the care of patients with long term conditions. They told us this more cohesive approach to monitoring patients had improved outcomes for patients.

Data for 2024 to 2025 financial year from the ICB showed that that The Penrhyn Surgery was performing highly for the management of long-term conditions (LTC) as all LTC indicators had met or exceeded ICB targets. This included, Diabetes Reviews, Asthma/COPD reviews with action plans, Hypertension monitoring, CKD coding and eGFR management and annual reviews for heart failure, stroke/TIA and mental health.

From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. The service had a comprehensive programme of quality improvement activity and reviewed the effectiveness and appropriateness of care provided.

The provider submitted clinical audits which they had carried out to improve outcomes for patients. These included an audit of Serum Lithium Level Monitoring and an audit of patients of childbearing age (12-55 years) prescribed a medicine to treat epilepsy. Findings from audits were shared with staff to help identify further areas for improvement

The provider reviewed the uptake of childhood immunisations and cervical screening. The service had not met the WHO based national target of 95% for five of the childhood immunisation uptake indicators (01 April 2023 to 31 March 2024). The service was aware of these results and provided evidence of actions taken to improve the uptake of childhood immunisations. For example, the service used a recall tool to help identify children who were at highest risk of delayed immunisation. The service had taken action on providing information to people in the community, about childhood immunisation. We saw unverified data which showed improvements in targets over the last 12 months.

The service had not met the national target of 80% uptake for cervical screening (NHS Digital data 30 June 2024). Data we reviewed showed a downward trend in the uptake of cervical screening among younger patients (aged 25 to 49 years) However, there were demonstrable improvements in the uptake of cervical screening in the patient cohort aged 50 to 65 years. The service told us the PCN provided screening clinics on Saturdays and Sundays. The service had a recall system and sent texts to patients with information about cervical screening and a self-booking link.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood the requirements of legislation and guidance when considering consent and decision making. Clinical staff had completed training in the Mental Capacity Act. Capacity and consent were clearly recorded. Staff gave patients information about care and treatment in a way they could understand and offered appropriate support and time to make decisions. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.