The Penrhyn 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

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination.

We carried out an announced targeted assessment of the responsive key question at The Penrhyn Surgery on 15 November 2023. The assessment took place remotely. As a result, the responsive key question rating was changed to requires improvement. At this assessment we found improvements had been made. The rating has changed to Good.

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 were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

The service mostly worked in partnership with people, to decide how to respond to any relevant changes in people’s needs. 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.

Results from the national GP survey 2025 showed 81% of participants felt they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. The local average was 88% and 91% national results.

The service made adjustments when patients found it difficult to access services. For example, if patients were unable to complete the online consultation process in order to book an appointment, practice staff would assist them in booking an appointment.Leaders told us that staff had completed customer service training which emphasised patient centred care.

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

People received care and treatment that considered their diverse health and social care needs. We saw the service worked in partnership with other services to meet the needs of its patient population. The service had tailored its services to meet the diverse needs of its community, for example, building relationships with community groups to promote the take up of screening programmes. The service was actively involved in their local primary network, where they worked with other services to improve local health inequalities.For example, staff told us the service was involved in delivering a bowel cancer screening programme, to help detect bowel cancer before symptoms start.

The service attended both anticipatory and current multidisciplinary meetings regularly to review and improve patient care. Patients could book appointments online, in person or by telephone, longer appointments were offered to those with more complex needs. People in vulnerable circumstances were easily able to register with the service, including those with no fixed abode such as homeless people and Travellers. Patients could be referred to the community mental health nurse, who worked one day a week at the service.

The service had a diverse workforce. This helped staff to understand patients’ needs better and deliver more effective and responsive care. Leaders told us the workforce was stable, and this ensured better continuity of care.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. There were policies and procedures for staff to follow to ensure people had information that was tailored to individual needs. This included making reasonable adjustments for disabled people, interpreting and translation for people who don’t speak English as a first language and for deaf people who use British Sign Language. We saw information about interpreter services was visible in the reception area. The service complied with the Accessible Information Standard and staff had completed training. Information provided by the service met the Accessible Information Standard. Patients were informed as to how to access their care records. Staff had access to the data protection and accessible information policies online.

Data from the GP Patient survey 2025 showed that only 30% of patients found it easy to contact the service using their website. This was lower than the local47% national averages of 51%. Staff told us that the service website had been significantly improved in response to patient feedback. It included easy read and translation options, navigation help, and a quarterly service newsletter.

In response to patient feedback regarding online appointments the service had opened the online consultation portal for longer to improve access. Also, following feedback from patients, the service had updated their phone system to provide more information for patients about appointments.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result. The provider ensured people, and their relatives were given opportunities to provide feedback. The provider worked with people to understand and manage risks enabling them to make informed decisions. Patients were informed of any adverse effects of the medicine they were taking.

We found people had multiple ways to provide feedback. This included through NHS websites, the complaints process, the NHS Friends and Family Test (FFT) and the national patient survey. When a patient submitted an online consultation, they could opt in to taking a short survey. Patients could also contact the PPG and there was a suggestions box.

The service demonstrated the importance of listening to all negative feedback which was included for discussion at learning events where the responses were shared and discussed. The full team were involved in reviewing outcomes to maximise learning and support change.

We reviewed 3 complaints in detail and found the process to be satisfactory. Learning from incidents and complaints resulted in changes that improved care for others. We saw complaints were managed in line with the service’s policy. The complaints policy was available on the practice website and included information for patients about how to contact the Parliamentary and Health Service Ombudsman.

Leaders had carried out analysis of the annual summary complaints received (from January 2024 to December 2024) and had identified themes. Verbal complaints were also documented and responded to. The provider was able to nominate another senior member of staff to investigate complaints when there was a conflict of interest so that there was independent oversight. We saw evidence of documented clinical learning events to drive improvement and shared learning.

CQC received feedback from 6 people who used the service in the last 12 months. We received some negative feedback about people’s experience of the complaints process and how the service had communicated information to people. The North East London Integrated Care Board (ICB) had received 12 complaints from patients in the last 12 months. Some complaints were still under investigation by the ICB complaints team, but the ICB told us none of the complaints they had investigated, had been upheld.

The national GP patient survey carried out from January to March 2025 had 94 responses. This found 79% of patients stated the healthcare professional was fairly or very good at listening to them during their last general service appointment. This was lower than the local (82%)and national (87%) averages.

The provider had formed an action plan to improve patient satisfaction following the national GP patient survey. They provided evidence of how they used FFT data and online consultation survey responses to drive improvement. For example, following feedback from patients, the service changed the opening times of the online consultation portal to between 11am and 2pm daily, during the week. Following patient feedback from the October 2024 telephone survey, the phone message was redesigned into a health navigation pathway, reducing average call wait times from 60 to 5 minutes (as of August 2025). The service had conducted its own independent patient satisfaction survey.

The service had an active PPG who had supported the service in implementing improvements. From meeting minutes, we viewed we saw that PPG members had opportunities to raise questions, and they received a response from practice staff.

The service made sure that people could access care and support. The provider demonstrated how people who may face barriers based on their protected characteristics could access the care and treatment they needed when they needed it. The service was proactive in ensuring patients had access to appointments. They recognised some patients experienced delays in getting through to the service to access appointments.

The service used people’s feedback and other evidence to actively seek to improve access for people more likely to experience barriers or delays in accessing their care. Although data from the National GP Patient Survey published July 2025 showed some lower performance in terms of patient’s experience of access, the service had more positive feedback from patients interviewed by Healthwatch Waltham Forest and from those who responded to the Family and Friends test. The service provided evidence to show that they were reviewing, monitoring, and making changes to further improve patient experiences in relation to access.

The most recent GP Patient Survey data, from 2025, showed 37% of patients found it easy to get through to the GP practice by phone, which was lower than the local average 51% and national average of 53%. The service was aware of the lower score in relation to the GP patient survey and had analysed the data, reviewed the survey with the PPG and came up with an action plan, they also undertook their own patient survey.

In response to the National GP Patient Survey and feedback from members of the community the provider had identified changes to improve access to the service. For example, they had extended appointments for people with a learning disability. The service had recently introduced vulnerable patient appointment slots. Longer appointments were also available to for patients in general if the GP felt this was needed. Patients could still request a phone appointment. The service had installed a new cloud-based telephony system in February 2024, which gave information about a patient’s place in the phone queue and also offered the option for the surgery to phone the patient back to save waiting on the phone. Patients were able to book appointments in advance and the service actively promoted the use of the NHS app. In March 2025 the service introduced a dedicated email for prescription requests and queries. Staff told us this had reduced the need for patients to have to call the practice or come in person to the surgery with a prescription query.

The provider had made reasonable adjustments to support equity in access. The premises was accessible. In November 2024, provider had completed an 18-month refurbishment and extension of the surgery. This had increased the number of consulting rooms from 5 to 10 of which 7 were on the ground floor and accessible for wheelchair users or patients with mobility issues. Treatment rooms were available on the ground floor and there was a new disabled access toilet and a new wheelchair access ramp at the front of the surgery. There was provision of baby changing facilities and the creation of a buggy park outside the premises.The Penrhyn Surgery had remained fully open throughout the refurbishment work maintaining service continuity and even increasing appointment availability. From April 2024 to April 2025, the average weekly appointments offered per 1,000 patients was 174.5 which was significantly above the recommended minimum of providing 70 appointments per week per 1000 patient. This was an 11.3% increase in appointment volume since 2023.

For people with hearing difficulties there was a new mobile hearing loop system in reception which could be moved to assist patients during their consultation. In addition, there were translation services available to support patients whose first language was not English, together with access to British Sign Language interpreters.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this. There was evidence that leaders considered the needs of people with different protected characteristics and made reasonable adjustments to support equity in experience and outcomes. Feedback from people using the service, both to the provider and to CQC, was positive. Staff treated people equally and without discrimination. Leaders proactively sought ways to address any barriers to improving people’s experience and worked with local organisations, including within the voluntary sector, to address any local health inequalities. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. The service had engaged with their vulnerable population groups to discuss any barriers to healthcare and how best staff could support them in accessing care. Staff used reasonable adjustment alerts in patient records to support people’s access to healthcare and to notify staff of any specific needs, such as the requirement for double appointments, communication assistance, or referral to a social prescriber. The practice has also introduced vulnerable patient appointment slots, offering same-day access for patients with urgent care needs.

The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and Travellers. Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to the internet.

People 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 people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. This information was shared with other services when necessary. Staff kept a palliative care register and told us patients were reviewed according to their needs and discussed during practice staff meetings. The service had processes in place to review if care and preferences had been met in line with patients wishes. We did not collect patient experience feedback that related to planning for the future.