Background to this inspection
Updated
15 December 2021
Penshurst Gardens Surgery is located at 39 Penshurst Gardens, Edgware, London HA8 9TN. Penshurst Gardens Surgery is a teaching practice with a clinical team that includes two GP partners, one salaried GP, two practice nurses, one Healthcare Assistant and one clinical pharmacist. There are 8 members of non-clinical staff including the practice manager.
The practice was registered with the Care Quality Commission in April 2013 to carry out the following regulated activities: diagnostic and screening procedures, treatment of disease, disorder or injury, maternity and midwifery service.
When the practice is closed, patients are directed to contact the local out of hours service and NHS 111. Contact details are communicated in a recorded message accessed by calling the practice when it is closed, or by accessing the information on the practice website.
Updated
15 December 2021
OVERALL SUMMARY
We carried out an announced inspection at Penshurst Gardens Surgery on 20 July 2021. All key questions were rated as good apart from ‘responsive’ which we have rated as requirements improvement due to significantly low patient feedback around access to the service. Overall, the practice is rated as Good.
Safe - Good
Effective - Good
Caring - Good
Responsive – Requires Improvement
Well-led - Good
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Penshurst Gardens Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
On 20 July 2021 we conducted a comprehensive inspection to follow up on concerns that were brought to our attention. We found no evidence to support those concerns during this inspection.
We previously inspected the practice in February 2017, the practice was rated good at that time.
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
- Short site visit
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 and for all population groups. We found that:
- When something went wrong, there was an appropriate, thorough review that involved all relevant staff. Lessons were learned and communicated to support improvement.
- The practice’s performance for childhood immunisations and cervical screening was lower than the national targets. The practice had made improvements to the uptake for childhood immunisations and had a plan in place to improve the uptake for cervical screening.
- Services were planned and delivered in a way that met the needs of the local population.
- Patient satisfaction was in line with national target apart from about access to the service.
- Leadership, governance and practice management arrangements promoted the delivery of high-quality, person-centred care.
Whilst we found no breaches of regulations, the provider should:
- Continue to take action to improve childhood immunisations and cervical screening uptake rates.
- Continue to review prescribing of hypnotics.
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