Archived: Penvale Park Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Penvale Park Medical Centre on 23 September 2015. Overall the practice is rated as requires improvement.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed, with the exception of those relating to infection control and health and safety. In particular the decontamination procedures.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance.

• Non-clinical staff performing chaperone duties had not received training or disclosure and barring checks (DBS). The practice had not completed a risk assessment to determine if a check was required.

• 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 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 sought feedback from staff and patients, which it acted on.

However there were areas of practice where the provider needs to make improvements.

The areas where the provider must make improvements are:

• Review infection control procedures including the carrying out of infection control audits. They must complete a risk assessment for the management, testing and investigation of legionella and implement any recommended checks to the water system. They must stop procedures that involve the use of locally sterilised equipment and adopt the NHS England decontamination guidance before these procedures recommence.

• Complete the business continuity plan and make it accessible to all staff.

• Ensure there are systems and processes in place to mitigate risks relating to the health and safety of patients when carrying out regulated activities. They must carry out regular fire drills to ensure staff know what to do in the event of a fire. They must complete a risk assessment to determine the need for an onsite defibrillator and document mitigating actions to take if they do not have one. Where non-clinical staff perform chaperone duties, the practice must provide training for this role and record a risk assessment on whether a DBS check is required.

• Start a patient participation group (PPG) to gather patient feedback.

Where a practice is rated as inadequate for one of the five key questions or one of the six population groups it will be re-inspected within six months after the report is published. If, after re-inspection, it has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place it into special measures. Being placed into special measures represents a decision by CQC that a practice has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice