The Care Quality Commission
  • Doctor
  • GP practice

Jenner Healthcare

Overall: Good read more about inspection ratings

The Medical Centre, Wisbech Road, Thorney, Peterborough, Cambridgeshire, PE6 0SD (01733) 270219

Provided and run by:
Jenner Healthcare

All Inspections

11 July 2023

During an inspection looking at part of the service

We carried out an announced follow up inspection at Jenner Healthcare on 11 July 2023. Overall, the practice is rated as good.

Safe - Requires improvement.

Effective - rating of good carried forward from previous inspection’

Caring - rating of good carried forward from previous inspection’

Responsive - rating of good carried forward from previous inspection’

Well-led - rating of good carried forward from previous inspection’

Following our previous inspection on 13 April 2022 the practice was rated good overall and for all key questions but requires improvement for providing safe services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Jenner Healthcare on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up on breaches of regulation from a previous inspection in line with our inspection priorities.

How we carried out the inspection.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.
  • Staff questionnaires.

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 found that:

  • The practice was unable to evidence that they provided care in a way that kept patients safe and protected them from avoidable harm.
  • The practices system for managing safety alerts was not fully embedded and did not ensure safe prescribing for all patients.
  • The practice had improved their systems and processes for safe recruitment. We found all staff had received a Disclosure and Barring Service (DBS) checks or a risk assessment.
  • We found the management team had full oversight of the documentation held in staff records to ensure safe recruitment procedures had been followed in a timely way.
  • The practice could not evidence that all patients had a structured and comprehensive medicines review.

We found a breach of regulation. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition the provider should:

  • Continue to review and reduce where appropriate, prescribing rates for antibacterial medicines.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

13 April 2022

During a routine inspection

We carried out an announced comprehensive inspection at Jenner Healthcare

on 13 April 2022. Overall, the practice is rated as good.

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led – Good

When this service registered with us, it inherited the regulatory history and ratings of its predecessor. This is the first inspection of Jenner Healthcare under the registered provider Jenner Healthcare who became the provider from January 2022.

We had previously inspected the practice under the previous provider registration in July 2019 and the practice was rated as requires improvement overall. Under our continuing regulatory history policy, the rating of requires improvement was inherited.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Jenner Healthcare on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on all key questions.

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
  • Staff questionnaires

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 did not always provide care in a way that kept patients safe and protected them from avoidable harm.
  • The practice had a system for manging safety alerts but had not continued to monitor historical alerts and ensure safe prescribing for all patients.
  • The practice had not fully ensured safe recruitment processes. We found not all staff had received a Disclosure and Barring Service (DBS) checks or a risk assessment.
  • We found the management team did not have full oversight of the documentation held in staff records to ensure safe recruitment procedures had been followed in a timely way.
  • The practice did not always evidence that all patients had a structured and comprehensive medicines review. We identified there was some inconsistency with coding of long-term conditions within the clinical system, meaning some appropriate or necessary care was not always given in a timely manner.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • 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 way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We found a breach of regulation. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

  • Continue to encourage patients to attended for childhood immunisations and encourage patients to attend for the national cervical screening programme to increase uptake.
  • Continue to conduct patient feedback exercises to make improvements to services.
  • Improve accessibility for staff in respect of contacting a Freedom to Speak Up Guardian if they wish.

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

4 July 2019 to 5 July 2019

During a routine inspection

We carried out an announced comprehensive inspection at Octagon Medical Practice on 4 and 5 July 2019 as part of our inspection programme. The service was previously inspected in October 2016 as Thorney and Eye Medical Practice and was rated Good overall.

Since July 2018, Octagon Medical Practice has merged with eleven other local practices to provide primary medical services to approximately 156,000 patients in the Peterborough, Wisbech, March and Huntingdon areas of Cambridgeshire and Peterborough.

Octagon Medical Practice is developing and has plans to merger a further eight practices. To ensure effective management they have separated into three local regions; North, East and West. The eight practices that are awaiting formal merger, are separately registered with CQC under their original registration and did not form part of this inspection.

This inspection focussed on the North region comprising 11 merged practices (and one awaiting formal merger). We inspected seven of these sites including one dispensary:

  • Thorney and Eye Medical Practice – the providers registered location (Thorney Surgery PE6 0SD and Eye Surgery PE6 7UX)
  • Jenner Healthcare Centre, PE7 1EJ
  • Nene Valley Medical Practice, PE2 5GP
  • Westgate Surgery, PE1 1NE
  • Park Medical Centre, PE1 2UF
  • Thomas Walker Surgery, PE1 2QP (Comprising Thomas Walker Surgery, Minster Medical Practice and Huntly Grove Practice)

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 Requires Improvement overall.

We rated the practice as Requires Improvement for providing safe services because:

  • We found within the dispensary at one branch site, the practice did not have appropriate systems in place for the safe management of medicines. We found out of date medicines and although standard operating procedures (SOPS) were in place there was no evidence to demonstrate that staff had read and understood them. There was no record that staff had regular reviews or assessments to ensure they were competent to undertake their roles and responsibilities or that they were compliant with SOPs, standards, guidelines and best practice. In addition, there were limited records of dispensing errors and near misses and fewer than expected for a practice dispensing to 3000 patients where they had recorded them there was no evidence of action taken to reduce the likelihood of recurrence.
  • There was an organisation wide infection prevention and control policy in place however, this was not site specific and therefore not wholly effective.
  • Recruitment checks had not always been carried out in line with regulations and guidance; the organisation had identified this issue prior to our inspection and had an action plan in place to address it.

We have rated the effective domain as requires improvement overall.

We rated the population groups of older people, families, children and young people, people whose circumstances make them vulnerable and people experiencing poor mental health (including people with dementia) population groups as good. We have rated the people with long term conditions and working age people population group as requires improvement because:

  • Some Quality and Outcomes Framework indicators were below local and national averages, there were also higher than average exception reports for patients from some branches.
  • Cancer screening data for patients across all sites varied with some branches having lower than average screening rates.

We rated the practice as Good for providing caring, responsive and well-led services and in all population groups because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review infection prevention and control policies to ensure these are site specific.
  • Continue to implement local risk assessments for the safe storage of substances hazardous to health.
  • Review and improve the system for identifying, recording, investigating and learning from near misses and significant events in the dispensary.
  • Monitor and improve the quality of care provided to patients with long term conditions and for national cancer screening programmes.

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

10 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 3 March 2016. We issued a requirement notice in relation to good governance. The practice sent in an action plan informing us about what they would do to make the necessary improvements:

The practice had not undertaken a robust legionella risk assessment.

  • The practice had not ensured that all medicines needing cold storage were kept in an appropriate fridge.

  • The practice had not ensured that dispensing staff had received a documented competency assessment.

  • The practice had not ensured that oxygen warning signs were displayed on doors where it was held.

They told us these issues would be addressed by 30 June 2016 and provided us with evidence to show they had taken the action to address the concerns.

We undertook a desk top review on 10 October 2016 to make a judgement about whether their actions had addressed the requirements.

The overall rating for the practice is good. You can read our previous report by selecting the ‘all reports' link for on our website at www.cqc.org.uk

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice


3 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Thorney Medical Practice on 3 March 2016. Overall the practice is rated as good.

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.
  • Urgent appointments with a GP were available on the same day.
  • Information about services and how to complain was available and easy to understand.
  • 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 practice was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvement are;

  • Ensure a Legionella policy and risk assessment are in place.
  • Oxygen warning signs are displayed on doors where it is held.
  • Ensure all medications needing cold storage are kept in an appropriate fridge.
  • Ensure dispensing staff have received a documented competency assessment.

The areas where the provider should make improvements are;

  • Ensure prescription forms are tracked in line with national guidance.
  • Have a system in place to check minor surgery histology specimen results are returned from the laboratory.
  • Ensure phlebotomy is only undertaken in rooms with flooring and surfaces that meet the requirements of the Code of Practice for health and adult social care on the prevention and control of infections and related guidance.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

17 October 2014

During an inspection looking at part of the service

We found there were systems in place to manage the prevention and control of infections. Patients, staff and other visitors were safe from the risk of acquiring a health care associated infection.

The premises appeared visibly clean, were well lit and warm. Statutory inspections of water systems, electrical equipment and other health and safety checks had been implemented. The premises and its equipment were safe for patients, staff and other visitors to access.

18 February 2014

During a routine inspection

A valid consent was obtained from patients or their representative before any care or treatment was provided. This included that for minor operations and immunisation programmes. Patients' advanced decisions about their future care were respected.

Patients' care needs were based upon an assessment at their initial registration at the surgery. One patient said, "I can always get to see the GP of my choice. I never have to wait long for an appointment". The majority of patients we spoke with told us that they had a positive experience of using the services offered by Thorney Medical Practice and its Eye branch surgery.

There were systems in place to manage the prevention and control of infections. However, we found that these were not always effective. Patients, staff and other visitors were at risk of acquiring a health care associated infection. We could not be confident that spillages would be safely cleaned up.

The premises were well lit, warm, secure and smelt clean. However, statutory inspections of water systems, electrical equipment and other health and safety checks had not always been reliably completed. There was a risk that the premises and its equipment were not safe for patients, staff and other visitors to access.