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Review carried out on 20 June 2019

During an annual regulatory review

We reviewed the information available to us about Pembroke Surgery on 20 June 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 9 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pembroke Surgery on the 9 March 2016. Overall the practice is rated as good. The practice was rated as good for the provision of safe, effective, caring, responsive and well led services.

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. However, some patients reported having to wait sometime to see their preferred GP.
  • 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:

A GP in the practice had received training in ultrasound scanning and provided this service to patients of the practice. The service supported patients who were pregnant with routine and non-routine scans and assisted with the diagnosis of abdominal conditions such as gallstones. The GP worked closely with specialists and consultants at the local hospital and was able to seek advice, as required. This offered an improved service and experience for patients of the practice with a reduction in referrals and admissions, more rapid diagnosis and increased scans for pregnant women offering reassurance with early pregnancy concerns.

The areas where the provider should make improvement are:

  • Ensure the system for monitoring training is more robust and implement a more consistent approach to the recording of training documentation and dates.

  • Consider a review of the PPG virtual group and how this could be further developed to ensure enhanced engagement and involvement with the practice.

  • Review the cervical screening and breast cancer screening to increase uptake to nearer the national average.

  • Clearly display comments and compliments forms in reception.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice