The Care Quality Commission
  • Doctor
  • GP practice

The Penryn Surgery

Overall: Good read more about inspection ratings

Saracen Way, Penryn, Cornwall, TR10 8HX (01326) 372502

Provided and run by:
The Penryn Surgery

All Inspections

8 March 2022

During an inspection looking at part of the service

We carried out an announced inspection at The Penryn Surgery on 8 March 2022. Overall, the practice is rated as Good.

The ratings for each key question are

Safe - Good

Effective – Good

Caring – Good (carried over from previous inspection)

Responsive – Good (carried over from previous inspection)

Well-led – Requires improvement

Following our previous inspection on 4 December 2018 and 5 December 2018, the practice was rated Good overall and Good for all key questions. The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Penryn Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Cornwall. To understand the experience of GP Providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

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 short site visit that included an inspection of the dispensary

We inspected two of the provider’s three locations on the same day; The Penryn Surgery, Saracen Way and The Penryn surgery, Stithians. The provider’s policies, procedures, staff and patient lists are aligned across both locations. The reports for both locations reflect this.

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.
  • The dispensary was safe and provided a valuable service to patients.
  • Patients received effective care and treatment that met their needs.
  • 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 an open and supportive culture, where there was a focus on improvement.
  • There were gaps in some of the practice’s governance arrangements. This had resulted in the incorrect registration of the practice with the Care Quality Commission.
  • Risk management was not embedded.

We found a breach of regulations. The provider must:

  • Operate effective systems and processes to make sure they have good governance, including assurance and auditing systems to promote improvement in quality and safety. This includes
    • developing an effective audit programme and risk management system
    • developing a system for reviewing historical safety alerts
    • developing an overarching system for monitoring staff training
    • ensuring the partnership is correctly registered and notifying and submitting applications for changes in registration in a timely way.

The provider should:

  • Continue to work towards achieving all nursing staff trained to level 3 safeguarding children and adults.
  • Complete the programme for replacing cloth-covered chairs with wipe clean chairs.
  • Review the approach for managing test results to ensure any risks are identified and mitigated.
  • Continue the programme of reviewing patients prescribed high risk medicines in line with best practice guidance.
  • Continue to work with patients within the Primary Care Network to create an effective patient participation group.

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

4 to 5 December 2018

During a routine inspection

This practice is rated as Good overall. (Previous inspection December 2015 – Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Penryn Surgery, visiting all three locations including the dispensaries at Penryn Surgery, Mawnan Smith Surgery and Stithians Surgery on 4 and 5 December 2018. The inspection was a routine inspection as part of our inspection schedule.

At this inspection we found:

  • The practice focussed on safety. The majority of systems were clear facilitating the management of risk across all three registered locations. The practice thoroughly investigated safety events and learned from them improving processes. However, there was a lack of consistency in the way complaints and significant events were documented, which could affect the governance of these processes by the practice.
  • Audit was embedded, with the practice routinely reviewing the effectiveness and appropriateness of the care it provided. Care and treatment was always delivered according to evidence-based guidelines.
  • All the feedback from 12 patients at the inspection was positive about staff treating them with compassion, kindness, dignity and respect.
  • People’s individual needs and preferences were central to the planning and delivery of flexible tailored services. For example, patients could attend any of the practice sites in Penryn, Mawnan Smith or Stithians for an appointment at a time to suit them.
  • Patient feedback about the appointment system had been listened to. The practice had significantly increased patient access to appointments online facilitating easier access for working people.
  • The practice continued to provide a daily on-site clinic at the local university to meet the needs of the students (25% of the practice population). Students were able access to a GP without disrupting their academic studies. They liaised closely with student support services to provide additional mental health support and monitoring.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation. Proactive succession planning based on staff development and training of future GPs, doctors and practice nurses was evident at this training practice.
  • The practice was an active research practice in the Southwest, supporting and recruiting patients for research studies to improve care and treatment outcomes for patients.

We saw two areas of outstanding practice:

The practice had responded to increasing numbers of patients presenting with gender dysphoria, for whom there were limited local and regional services available. An information pack had been developed for patients, including signposting to national support agencies, referral processes to the regional gender dysphoria clinic, transition and post-surgery health screening (female to male ongoing eligibility for breast and cervical screening).

The practice held an immunisation event, with children’s entertainer, aimed at hard to reach families to increase immunisation uptake. The first event lead to seven children being vaccinated. Children were given a bag with presents for being immunised, making it a positive experience for them. The practice planned further such events and intended to hold these at the weekend.

There were areas where the provider could make improvements and should:

Review the significant event (SEA) and complaints processes to ensure there is consistent documentation of risks, actions, change and embedding for safe governance.

Develop a consistent style of response to complaints providing both empathy and timeline information for patients.

Review the arrangements for storing and monitoring of blank prescription stationery at Stithians Surgery to ensure that best practice guidance is being followed and risks minimised.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

16 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Penryn Surgery on 16 December 2015. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

We saw one area of outstanding practice:

The practice had developed a daily on site clinic at the local university to meet the needs of the students (which relates to 24% of the practice population) and allows students easy access to a GP without disrupting their academic timetables. They liaise closely with student support services to provide additional support.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice