The Penrhyn 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

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

At our last assessment, we rated this key question as Good. At this assessment, the rating has remained as Good.This meant there were effective governance and management systems. Information and data was used appropriately to monitor risk, performance and quality of care.

This service scored 82 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff and leaders actively monitored and anticipated current and future risks to delivering the strategy, including relevant local factors. Staff described good teamwork and a service that was clear on its function to work in the interests of patients, providing the safest patient experience they could.

High standards were promoted and owned by all practice staff and teams worked together across all roles. All staff we spoke with shared the provider’s desire to deliver high quality patient-centred care and foster a strong partnership with patients to achieve the best possible health outcomes.

Leaders and staff understood their patient population, their cultural needs and challenges. The leaders had developed The Penrhyn Surgery Way which set out the service’s mission which was ‘to provide high-quality, patient-centred care that is safe, accessible, and responsive to the needs of our community. We are committed to treating every individual with dignity, respect, and compassion, while promoting health, preventing illness, and improving wellbeing’.

Staff told us it was a positive workplace, where they felt well supported by their leaders. All staff had contributed to the development of the service’s vision and strategy, which was kept under review. The service had developed values that would help them achieve this vision. The values included delivering a professional, safe and equitable service to patients. Most staff demonstrated a well-developed understanding of equality and diversity, and how to prioritise safe, high-quality care.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

There was constructive engagement with staff and a high level of staff satisfaction. Staff told us they were happy working at the service and that leaders were approachable and responded to any concerns raised. Staff used words such as “supportive”, “approachable” and “open” when they described leaders who they worked with. Leaders told us they worked to foster a culture of staff wellbeing. This was supported by initiatives such as a weekly 30-minute step together activity and provision of an accessible green space at the rear of the practice, for staff to use. The service had an employee assistance programme for staff, which provided advice and counselling.

The leaders told us they operated a no-blame learning culture which would provide all staff with an open and equal working relationship. Leaders we spoke with understood the importance of protecting individuals from discrimination and promoting equality in the workplace.

One of the GP partners said, “we are consistently reviewing our systems to improve our service”.The practice had gathered views from the patient participation group (PPG) and had used them to improve the services provided. For example, improving access, expanding the surgery and doubling the number of consulting rooms, recruiting more staff, and working in partnership with the PPG. Leaders told us they had developed their webpage making it more user friendly and informative and leaders had installed the new cloud-based telephony system which gives information about a patient’s place in the phone queue and also offers the option for the surgery to phone the patient back to save waiting on the phone.

We were provided with feedback from four GPs, working at the practice, that stated the leadership at Penrhyn was visible and supportive. For example,one GP described the service as an “exceptional place to work”, another GP staff member said leaders “genuinely listened to staff” and that they were “impressed with the practice’s commitment to support its most vulnerable patients”.

We saw the leadership team (GPs and clinical leads) worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff said there were no barriers to speaking up and their views were listened to and acted upon. This aligned with the management approach of being actively engaged with staff to seek their views. For example, leaders carried out a staff survey every six months.

The service had a whistleblowing policy with guidance for staff to approach external organisations should they not be confident to raise concerns internally. Leaders told us they were aware that staff may not feel able to speak up because one of the GP Partners was also the Practice Manager. Leaders had established freedom to speak up arrangements with the local GP federation and leaders told us they had arranged for one of the salaried GPs at the service to be a speak up champion for staff to speak with. Staff were aware of how to raise concerns. Processes ensured that when things went wrong, people received an apology and were told about action that would be taken to prevent the situation happening again.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff said they felt supported by management and told us they were valued by leaders. Leaders had taken steps to recognise and meet the wellbeing needs of staff, which included the necessary considerations for safe working, such as regular breaks and rest areas. The leaders held regular meetings where staff could raise concerns. Leaders had supported and made reasonable adjustments for disabled staff to carry out their roles. Staff reported being supported if they were struggling at work. Staff members told us they felt encouraged to contribute their ideas. Leaders told us they valued and supported all team members. Leaders had provided a quiet, green space at the rear of the surgery building where staff could take a break.

The service had a mission statement, recruitment policy and induction policy and procedures for new starters. Policies and procedures were embedded within the running of the service and clearly set out the practice’s vision in relation to its staff, ensuring all were equally treated and had access to opportunities for progression.

Policies and procedures to promote diversity and equality were in place. We saw senior leaders had addressed concerns related to discrimination. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support disabled staff were in place. Leaders provided training and resources to ensure staff were aware of their rights, including those related to equality, dignity, and respect in the workplace.

Governance was well-embedded into the running of the service. There was a strong framework of accountability to monitor performance and risk leading to the delivery of demonstrable quality improvements to the service. Leaders acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. There were effective risk management systems which ensured that recommendations from risk assessments related to the premises were acted on and that equipment was safe to use. A regular suite of searches of the clinal record system were being run to identify patient needs and ensure these were being met and our review of clinical records showed that this was effective.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Staff we spoke with knew who the relevant lead person was for areas such as safeguarding, infection control and significant events monitoring. Staff took patient confidentiality and information security seriously.

Performance management processes were effective, reviewed regularly, and staff consistently performed their roles in line with best practice. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. In addition to this the service held weekly huddle meetings where all staff could attend. This was to enable staff to input ideas and experiences. Leaders also said it assisted with the general oversight of managing the service. We reviewed a sample of minutes from all the meetings for the previous 3 months. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff.

The provider fully understood their duty to collaborate and work in partnership, ensuring services ran smoothly for patients. They regularly shared information and learning with partners and worked together to drive improvements. Between 2019 and 2024, the GP Partner co-developed a tracker tool with Waltham Forest GP federation, which was shared with other practices in the primary care network. Each practice could track its performance using health data from CEG searches, which allowed practices to share learning and good practice, creating a culture of collaborative improvement. The tracker tool was widely adopted across Waltham Forest primary care networks.

Leaders told us they collaborated with stakeholders and had integrated care meetings with district nurses, care agencies, mental health services, care coordinators and palliative care services. They had multidisciplinary team meetings monthly to discuss and improve outcomes for people with complex needs and a bi-monthly meeting with the health visitors to discuss child safeguarding. The service was actively involved in their local primary network, where they worked with other services to improve the local health inequalities.

The provider worked with other practices within their primary care network to offer extended access, referral to rapid response, domiciliary phlebotomy for housebound patients and flu, shingles and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services.

We received feedback from the PPG which meets every 3 months. They found the service to be open and honest and listened to concerns raised by PPG members, for example the PPG raised concerns in relation to access and the online consultation system, and patients being excluded. The service told them that any patients that had difficulties could still phone or come in person and staff would help them to complete the online form. The service changed the message on the surgery phone to help direct patients to the most appropriate response. The service and PPG had established a gardening group at the practice and leaders had provided an accessible and pleasant outdoor space at the rear of the practice, for the group to use. Led by the PPG and supported by practice leadership, the wellbeing garden was developed in response to local mental health and social isolation challenges during the Covid-19 period. The initiative transformed an underused outdoor space into a therapeutic garden accessible to both patients and staff. It was briefly stopped during the recent extension of the premises but had since restarted.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.There were established processes to ensure that learning happened when things went wrong, and from examples of good practice.

The service had a quality improvement plan in place to help drive improvements in services. They also had an action plan which reviewed data from the national GP patient survey, this focussed on staff and the appointment system. All staff were encouraged to put forward and test out new ways of working.

Leaders told us staff development was supported through the Penrhyn Leadership Academy, an in-house leadership and personal development programme led by the provider, who was a certified executive coach. This was open to all staff and was run quarterly. The service had provided development opportunities for staff across the practice to move into management positions, for example, leaders were supporting one member of staff to do a Practice Manager training course. Additional training for staff was proactively identified in response to staff feedback, or during the appraisal process.Leaders used learning sound bites to convey important information and embed learning across the team.

The leaders were involved in the development of a primary care network tracker to monitor performance targets. The tracker provided real-time access to contract and indicator performance data, allowing all stakeholders, clinical and administrative, to monitor weekly and monthly progress.

We were provided with feedback from four GPs, working at the practice, all were positive about the leadership and support for their professional development. Examples were provided of support to become an approved GP trainer in the past year, where adjustments were made at the practice to enable them to complete the supervisor course.