We carried out a review of the data available to us about Penn Hill Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Penn Hill Surgery, you can give feedback on this service.
We carried out an announced comprehensive inspection at Penn Hill Surgeryon 29 October 2015. Overall the practice was rated as good for effective, caring, responsive and well-led with the safe domain being rated as requires improvement. We issued one requirement notice for the following:
Breach of Regulation 19 of The Health and Social Care Act (Regulated Activity) Regulations 2014, Fit and proper persons employed. The requirement notice was for the practice to ensure all staff received appropriate employment checks prior to employment ensuring the safety of patients using the service.
Our key findings during this inspection were as follows:
The areas where the provider must make improvement were:
Review recruitment processes to ensure staff requiring a valid Disclosure and Barring Service check were in possession of this prior to their employment.
Review processes for staff undertaking a chaperone role who do not have a Disclosure and Barring Service check.
The areas where the provider should make improvement were:
Review the policy for legionella to ensure risks to staff and patients were effectively managed.
Review how governance arrangements were recorded and managed for complaints and risk assessments to ensure best practice was reflected.
A copy of the report detailing our findings can be found at www.cqc.org.uk.
We undertook a focused desk based inspection on the 21 November 2016 to follow up the requirement notice and to assess if the practice had implemented the changes needed to ensure patients who used the service were safe.
Our key findings across all the areas we inspected during this inspection were as follows:
The provider had updated staff recruitment policies to ensure staff were recruited appropriately. All staff files at the practice now contained evidence that appropriate recruitment checks had been undertaken.
The provider had updated the policy and procedure for staff chaperoning duties. Staff that chaperone patients had a Disclosure and Barring Service check in place and had received appropriate training for this extended role.
A Legionella risk assessment had been undertaken by an external contractor in August 2016. Subsequently, the provider had developed an action plan and was in the process of developing a system to undertake regular water system checks.
The provider had implemented a system of recording and monitoring complaints and risk assessments, ensuring best practice was reflected.
We found the provider had made the required improvements since our last inspection in October 2015. Following this focused inspection the practice is rated as good for providing a safe service and has an overall rating for the practice of good.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Penn Hill Surgery on 29 October 2015. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
We saw areas of outstanding practice:
The area where the provider must make improvement is:
The areas where the provider should make improvement are:
Chief Inspector of General Practice