The Penryn surgery

Updated 5 May 2022

The Penryn surgery is located in Stithians at:

Crellow Lane

Stithians

Truro

TR3 7BA

The provider, also referred to as The Penryn Surgery, operates three registered locations and a branch surgery at the university in Falmouth. The practice locations are:

• The Penryn Surgery, Saracen Way, Penryn, Cornwall TR10 8HX

• The Penryn surgery, Stithians Surgery, Crellow Lane, Stithians TR3 7BA

• The Penryn Surgery, Mawnan Smith Surgery, The Square, Mawnan Smith, Falmouth, TR11 5EP

The practice also has a consulting room at the nearby Penryn Campus that is open each day during the student term times.

The provider offers primary medical services to 20,669 patients. The patient population is 97.5% white, with the largest ethnic minority (0.8%) Asian. There is a relatively low number of older people and people aged 35 -65 years, as approximately 25% of the population is students. The practice population has a deprivation index of 7 where 10 denotes the least deprived.

The practice is situated within the Kernow Clinical Commissioning Group (CCG). The practice is registered to provide the following regulated activities: Diagnostic and screening, Surgical procedures, Family planning services, Maternity and midwifery services and Treatment of disease, disorder or injury.

The partnership at the practice was not correctly registered at the time of the inspection. There are 12 GP partners and two managing partners. The partners are supported by four salaried GPs, 11 practice nurses, one nurse practitioner, five healthcare assistants and a clinical pharmacist. As well as the practice manager and business manager, there are two assistant managers and teams of administrators and receptionists. Patients using the practice also have access to staff employed by the Primary Care Network, including social prescribers and first contact physiotherapists and paramedics.

Penryn Surgery is an approved training practice providing vocational placements for GP registrars. Two GP partners are approved to provide vocational training for GPs, second and third year post qualification doctors. Teaching placements are provided for medical students.

The Penryn practice, Saracen Way, is open between 8am and 6:30pm Monday to Friday. The Stithians Surgery is open weekday mornings 8.30am to 12.30pm. Extended hours opening is available 6.30pm-8pm two evenings a week for booked appointments and weekend morning clinics, usually two weekends per months. The website displays opening times. Outside of these times patients are directed to contact the out of hour's service by using the NHS 111 number.

The practice offers telephone consultations as a result of the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance. Patients are offered face to face appointments when this is assessed as appropriate and necessary.

Updated 5 May 2022

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