The Penrhyn Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same. This meant patients were protected by a comprehensive safety system and there was a focus on openness, transparency and learning when things went wrong. Staff took all safety concerns seriously.

This service scored 81 (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 had a proactive and positive culture of safety, based on openness and honesty. Clear processes were in place for reporting incidents, near misses, and safety events, and these were followed by staff. Leadership actively listened to safety concerns, investigated issues, and reported safety events. Lessons were always learnt to continually identify and embed good practice.Leadership actively listened to safety concerns, investigated issues, and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Staff consistently reported feeling comfortable raising concerns, quoting a blame-free environment where safety and learning were prioritised to prevent recurrence. Staff told us that incidents were discussed during team meetings, and the learning outcomes were shared with staff. Patient complaints and feedback was actively encouraged, systematically documented, and thoroughly investigated. All patient feedback was reviewed to identify trends and themes that could drive improvements. Evidence showed that incidents, complaints and any negative feedback were routinely discussed in practice meetings, with the full team involved in reviewing outcomes to maximise learning and support change.

There was a system in place to respond to safety alerts. Overall, the provider had effective systems to manage and respond to safety alerts. We saw evidence of clinical audits in response to MHRA safety alerts.We found 3 out of 31 patients identified that had not been informed promptly of any potential adverse effects of the medicine they were taking. Leaders quickly addressed this concern once we had raised it. Following our inspection, leaders took action to improve oversight of safety alerts.

Representatives from the PPG felt the provider took concerns seriously and proactively made improvements to the service. The service had conducted their own patient survey. The service had a duty of candour policy in place.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The service had robust systems in place to ensure information was effectively shared across teams and agencies, enabling the delivery of safe, coordinated care. Staff gave examples of patients on their safeguarding register moving from child to adult services, and the support they continued to need. Other examples included diabetes pathways and working closely with the local partners to care for patients on the palliative care register.

Clinicians followed established care pathways for diagnosis, treatment, and referral to specialist services. There was a system to ensure referrals to specialist services were documented and contained the required information. The service had processes in place to monitor urgent (2 week wait) referrals and there were effective safety netting processes to ensure all patients were followed up. For example, staff followed a patient referral protocol to ensure routine, urgent, and suspected cancer (2WW) referrals were made in a timely, accurate, and safe manner, and that patients are kept informed throughout the process.Communications from secondary care, such as discharge summaries, were processed efficiently to ensure continuity of care.We reviewed workflow processes which demonstrated all test results were managed in a timely way, ensuring that abnormal results were acted upon without delay.

Reception staff were trained in care navigation and demonstrated a strong awareness of local services and support networks. This supported them to direct patients effectively, based on their needs, and promote preventative healthcare. There were systems in place for processing information relating to new patients. The service had a new patient registration policy.

The service was proactive in safeguarding people from the risk of abuse, working closely with partner agencies to ensure a coordinated approach. Clear systems and processes were in place to respond promptly when concerns arose about abuse or neglect. The service had up-to-date safeguarding policies for both adults and children which outlined safeguarding guidance, staff responsibilities and reporting pathways and were easily accessible to all staff. The service had a lead for safeguarding adults and children. All staff we spoke with were aware of who the lead was and how to escalate any concerns they had. They demonstrated how they would act if they suspected a patient’s safety was at risk.

Training records we reviewed showed most staff had received safeguarding training appropriate to their roles and responsibilities. However, although all non-clinical staff had completed level 1 safeguarding children and adults,we found 2 members of the admin team had not completed level 2 safeguarding children and adults, which was not in line with intercollegiate guidance. Immediatelyfollowing our inspection, leaders provided confirmation that all non-clinical staff had completed level 2 safeguarding children and adults. Staff we spoke with were able to demonstrate a good understanding of the safeguarding principles within the service.

Safeguarding registers for both children and adults were maintained and there was evidence of reconciliation of the registers. Safeguarding alerts were added to the clinical record system when relevant, ensuring that all team members were aware of ongoing concerns and could act accordingly.

The service worked with people to understand and manage risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were effective arrangements for supporting patients to identify manage and mitigate risks. We spoke with three members of the patient participation group who told us the service was open to discussing any concerns raised in respect of safety. The service had guidance for staff to identify and escalate risk to an appropriate clinician. The service was equipped to deal with medical emergencies (including suspected sepsis. All staff had been trained in basic life support.Patients were advised on risks related to their condition and actions to take if their condition deteriorated. The service operated an online consultation service to help triage patient queries and appointment requests. There was a clinical triage and on the day appointment team, where patients with urgent needs were triaged, responded to, and supported as appropriate.

The practice has implemented a locum handover template, completed at the end of each locum shift. Locum staff used the template to log patients requiring follow-up, referrals, potential safeguarding concerns, or any issues needing further review.

The service was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care. Risk management was well embedded and health and safety was recognised as the responsibility of all staff.

Facilities, premises and equipment were designed and used to meet the needs of all people who use the service. The surgery building had undergone extensive building work and refurbishment, and the maintenance and upkeep of the building internally and externally was good. Leaders had made significant accessibility improvements including wide corridors and accessible clinical space inside the premises, a new external mobility ramp, new disabled toilet facilities and assistive listening system for hearing aid wearers. The premises was very clean and equipped with appropriate resources to support effective infection prevention and control. Contracts were in place to ensure the premises were maintained to keep everyone safe.

The service demonstrated a proactive, comprehensive approach to risk management. Regular monitoring systems such as weekly emergency trolley checks and fire alarm testing, and six-monthly fire drills ensured that safety processes were well-embedded in daily operations. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. A fire risk assessment was done in December 2024. A health and safety risk assessment was carried out in July 2024. Electrical, gas and Legionella assessments had all been done in the last 12 months. We saw that all recommended actions from risk assessments related to the premises had been completed and that equipment was safe to use. Minutes we saw showed risk assessments were a standing agenda item for discussion at practice team meetings, where actions were reviewed with the whole team.

All staff had opportunities to practice emergency response drills and leaders had created a quick reference guide to support reception staff during medical emergencies, to ensure preparedness across the practice team. There was a business continuity plan in place to support any major service disruptions, which was monitored and reviewed. There were no concerns from staff about the health and safety arrangements.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Leaders used an electronic management tool to monitor completion of training.

There were a range of clinical and non-clinical roles within the service. Leaders used an electronic management tool to monitor completion of training. On the day of the site visit we reviewed 5 staff files clinical and non-clinical, and we reviewed the practice staff training matrix. We found most staff were up to date with mandatory training, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Staff participated in monthly protected learning time (PLT) sessions focused on learning and professional development.

The service submitted a recruitment policy reviewed in July 2025, which included the required checks to ensure safe recruitment. We reviewed 5 staff files and found safe recruitment processes were followed.

For example, managers had completed all required pre-employment checks, including Disclosure and Barring Service (DBS) clearance and satisfactory references and this was clearly documented in staff files. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable). There was also a record of checks of professional registration for clinical staff. There were clear induction processes for new staff which included induction checklists to support locums and ARRS staff and GP trainees, working at the service.

Managers organised 6 monthly anonymised staff surveys for staff to feedback on job role clarity, wellbeing, work-life balance, leadership, and professional development. The staff survey reflected high morale and strong support mechanisms. For example, 17 staff responded to the July 2025 staff survey and 100% of respondents reported they had a clear understanding of their job roles and responsibilities and 82% of staff reported that they felt supported by their managers.

The service was proud to have a diverse practice team. Staff across all roles confirmed there were sufficient numbers to deliver safe, high-quality care and that teamwork was effective. Robust systems were in place to manage sickness, absences, or staff turnover, meaning the service rarely needed to rely on temporary or locum staff.

The provider ensured clinical staff received effective support and supervision. For example, leaders provided daily debriefs and regular feedback for clinical staff to drive improvement. There was documented evidence in the patient records of clinical supervision. We saw that where nurses’ consultations had been discussed with a GP, this was recorded in the patient record.

The service thoroughly assessed and managed the risk of infection. They always quickly detected and controlled the risk of it spreading and always shared concerns with appropriate agencies promptly.The facilities and premises were clean, and systems were in place to prevent the spread of infection. Personal protective equipment (PPE) was well stocked and placed appropriately throughout the building. The provider assessed and managed infection risks, with clear roles assigned, including a dedicated lead for infection prevention and control. Staff had received training relevant to their roles.

Cleaning schedules were in place, and regular infection control and cleaning audits were conducted to maintain standards. The provider had created a new purpose-built storage space so cleaning equipment could be stored safely and according to best practice. Waste, sharps, and clinical specimens were managed carefully to keep everyone safe. Staff vaccinations were kept up to date in line with the latest UK Health Security Agency (UKHSA) guidance. There was a clear system for reporting infection concerns to the relevant agencies, such as for notifiable diseases.

A legionella risk assessment was carried out in December 2024, after building work was finished, to ensure compliance with legionella control and prevention. Identified issues were promptly addressed, and a follow-up assessment in July 2025 confirmed all deficiencies were resolved. The service had a safe water policy created in July 2025.

The service had a designated infection, prevention and control lead and all staff had had relevant training. A formal infection prevention and control audit was carried out by NHSE England in August 2024.Overall the practice showed compliance with IPC standards. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

There is a comprehensive system to proactively promote a strong safety culture for medicines optimisation. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. As part of our assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. These searches were completed with the consent of the provider, and to review if the service was assessing and delivering care and treatment in line with current legislation, standards and evidence-based guidance.

Our clinical review of patient records showed that medicines were consistently managed safely and the approach to medicines reflected current and relevant best practice and professional guidance. There was some notable achievement for monitoring medicines with specific risks that required monitoring.

We reviewed clinical records for patients who had been prescribed medicines which required monitoring. Our review showed that regular medicines reviews were carried out for people who used the service to ensure their medicines were safe and appropriate to their needs. Regular searches and audits were in place to ensure the service delivered timely reviews. A very small number of people were overdue checks relating to their medicines and the provider evidenced that all of those were rectified during the assessment process.

There was evidence that people taking medicines with specific risks that required monitoring, were appropriately monitored before their medicines were prescribed.Where more frequent monitoring was required, the provider had monitored medicines exceptionally well. For example, there was a process for monitoring patients’ health in relation to the use of warfarin and lithium and patients prescribed anticoagulant medicines and medicines to treat high blood pressure. We reviewed patient records and found that all patients had received the appropriate monitoring at the required frequency. There was appropriate clinical review prior to prescribing these medicines.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. The service had taken steps to ensure appropriate antimicrobial use to optimise patient outcomes and reduce the risk of adverse events and antimicrobial resistance. However, prescribing data we reviewed showed the service prescribed more broad-spectrum antibiotics comparatively than other practices. We raised this with the provider who shared evidence of regular audits to monitor broad-spectrum antibiotics prescribing. The most recent re-audit from July 2024 to December 2024 indicated a mixed picture and demonstrated further improvement in antibiotic stewardship was needed. Leaders felt this was largely attributable to out of hours services prescribing.

Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had systems to manage and respond to safety alerts and medicine recalls.