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Inspection Summary

Overall summary & rating


Updated 20 December 2016

Letter from the Chief Inspector of General Practice

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

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas



Updated 20 December 2016

When we undertook a comprehensive inspection in October 2015 we found the practice was rated as requires improvement for providing safe services. This was because the provider was not always completing appropriate recruitment processes and did not have systems to ensure the safety of patients and staff.

During the desk based inspection undertaken in November 2016 we found the provider had improved systems to keep patients and staff safe. The changes included:

  • The provider had updated and implemented a new policy and procedure to safely recruit staff and had completed a risk assessment or a Disclosure and Barring check, where appropriate, for all staff.

  • All staff who acted as chaperones had an enhanced Disclosure and Barring check in place and had undertaken the required chaperone training.

  • The complaints policy and procedure had been updated and all complaints wererecorded, managed and audited to ensure that patterns of reported complaints were identified and learning could be shared.

  • An external Legionella risk assessment had been completed in August 2016 and the provider had subsequently created an action plan which is due to be implemented in December 2016.

We found the provider had made significant improvement since our last inspection on 29 October 2015. Following this desk based Inspection we have rated the practice as good for providing safe services.



Updated 10 December 2015

The practice is rated as good for providing effective services.

  • Data showed patient outcomes were at or above average for the locality.
  • Staff assessed needs and delivered care in line with current evidence based guidance.
  • Clinical audits demonstrated quality improvement.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was evidence of appraisals and personal development plans for all staff.
  • Staff worked with multidisciplinary teams to understand and meet the range and complexity of people’s needs.



Updated 10 December 2015

The practice is rated as good for providing caring services.

  • Data showed patients rated the practice higher than others for several aspects of care.
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • Information for patients about the services available was easy to understand and accessible.
  • We saw staff treated patients with kindness and respect, and maintained confidentiality.



Updated 10 December 2015

The practice is rated as good for providing responsive services.

  • It reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified. The practice was involved in local Vanguard projects in regard of integrated care, they worked closely with a local college for patients with learning disabilities and supported students from a local higher education college.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • 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 and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.



Updated 10 December 2015

The practice is rated as good for being well-led.

  • It had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to this.
  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.
  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk however some aspects could be improved.
  • The partners encouraged a culture of openness and honesty. The practice had systems in place for knowing about notifiable safety incidents.
  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active and fully involved in improving services with the practice.
  • There was a strong focus on continuous learning and improvement at all levels.
Checks on specific services

People with long term conditions


Updated 10 December 2015

The practice is rated as good for the care of people with long-term conditions.

  • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority. Nurse lead roles included care planning, diabetes, asthma and chronic obstructive pulmonary disease (COPD).
  • Longer appointments and home visits were available when needed.
  • All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those people with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.
  • Trained health care assistants offered home visits for this service when necessary.
  • Some patients were managed by a tele monitoring service and increasing numbers of their most complex patients were being looked after in a shared care arrangement with the local Symphony complex care hub to optimise the care of their long term conditions. (The Symphony project provides new integrated care models for people with long term conditions in South Somerset).

Families, children and young people


Updated 10 December 2015

The practice is rated as good for the care of families, children and young people.

  • There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.
  • Patients told us children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.
  • 83.89% of female patients at the practice aged 25-64 had a record showing a cervical screening test had been undertaken in the preceding 5 years; slightly above the national average of 81.88%.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.
  • We saw good examples of joint working with midwives, health visitors, school nurses and other health professionals.
  • All patients had named GPs and families were kept together with one GP where they chose to see the same GP.

Older people


Updated 10 December 2015

The practice is rated as good for the care of older people.

  • The practice offered proactive, personalised care to meet the needs of the older patients in its population.
  • It was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.
  • All older patients living in residential or nursing homes had care plans which were reviewed annually or as required.
  • Alerts were put on the patient record system for patients with poor hearing, memory problems along with details of family contacts or requirement for home visits.
  • Home visits were provided for influenza vaccinations and phlebotomy when required.
  • All staff had either completed or were in the process of completing dementia awareness training.
  • Staff from the practice attended monthly palliative care meetings to discuss the active care of those patients nearing the end of their lives.

Working age people (including those recently retired and students)


Updated 10 December 2015

The practice is rated as good for the care of working-age people (including those recently retired and students).

  • The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
  • The practice was proactive in offering online services as well as a full range of health promotion and screening that reflected the needs for this age group.
  • Cervical smear appointments were offered early morning, lunchtime and in the evening to support working women and students.
  • The practice had received an award in 2013 for outstanding support of students with learning disabilities from a local college for exceptional services to their students. The practice provided a regular clinic at the college as well as medical health checks and routine appointments to the students. One of the practice nurses provided a detailed training session for staff at the college about helping students to manage their epileptic seizures. This was to ensure staff were safely skilled in supporting students. Enhanced services were provided to patients diagnosed with a learning disability. Services included visiting for influenza vaccinations, health promotion talks, staff training, new patient medicals and facilitated access to same day appointments.

People experiencing poor mental health (including people with dementia)


Updated 10 December 2015

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

  • All of the most vulnerable patients diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months.
  • The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia.
  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
  • There was a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
  • All staff in the practice had either completed or almost completed training in dementia awareness.
  • Staff had a good understanding of how to support people with mental health needs and dementia through attending training courses such as dementia awareness.

People whose circumstances may make them vulnerable


Updated 10 December 2015

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

  • The practice held a register of patients living in vulnerable circumstances including those with drug and alcohol problems and those with a learning disability.
  • It offered longer appointments for people with a learning disability if required.
  • The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people.
  • Reception staff were encouraged to offer flexibility in access to same day appointments for all vulnerable patients.
  • The practice had told vulnerable patients about how to access various support groups and voluntary organisations.
  • Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.