Pontesbury & Worthen Medical Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pontesbury Medical Practice on 3 March 2016. After the comprehensive inspection, the practice was rated as good overall with requires improvement in providing safe services. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Pontesbury Medical Practice on our website at www.cqc.org.uk. We undertook a focussed follow up inspection on 20 September 2016 to check that improvements had been made. The practice is rated as good for providing safe services and rated good overall.

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

• Patients were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• 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.
• General health and safety risk assessments had been completed, this included fire exits and maintenance records of all equipment including the wheelchair.
• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. Training included a documented induction system and safeguarding adults and children to the appropriate levels as well as basic life support.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• The provider was aware of and complied with the requirements of the duty of candour.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice ensured their recruitment arrangements included Disclosure and Barring Service (DBS) checks were completed for staff who had contact with potentially vulnerable patients and staff references recorded.
• Staff who provide a chaperone service were in receipt of chaperone training and had a Disclosure and Barring Service (DBS) check completed.
• The practice proactively sought feedback from staff including annual appraisals and patients, which it acted on.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pontesbury 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:

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.

• All opportunities for learning from internal and external incidents were maximised but not always as well documented as acted upon.

• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. The practice recognised the value of patient care over and above ensuring they achieved good Quality and Outcome Framework (QOF) results and they choose to maintain some former QOF requirements to ensure they captured all the quality aspects of the service they provided.

• Feedback from patients about their care was consistently positive.

• The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they met patients’ needs.

• The practice had a ‘Young Person Friendly Award’ and could see young people at school on short notice following a call from the school nurse. The practice welcomed young people and provided specific information for young people on the practice website and on the notice boards.

• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group. Examples included: arranging a dispensary home delivery service which included house bound patients.

• The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand.

• 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.

• Information about services and how to complain was available and easy to understand.

• There was a clear leadership structure and staff felt supported by the 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.

There were areas of practice where the provider must make improvements;

• Ensure Disclosure and Barring Service (DBS) checks are completed for staff who have contact with potentially vulnerable patients and complete a risk assessment until these are returned.

There were areas of practice where the provider should make improvements:

• Consider the completion of general health and safety risk assessments.

• Ensure that the wheelchairs for patient use have a record maintained of the annual maintenance checks completed.

• Consider risk assessing the three fire exits with three large steps in order to demonstrate how the practice would get all patients safely to the meeting point.

• Document verbal references and maintain this within the staff member’s personnel record.

• Consider the implementation of a documented staff induction system, signed and dated by staff on completion.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice