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Inspection carried out on 21 November 2016

During a routine inspection

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 www.cqc.org.uk.

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 carried out on 29 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Penn Hill Surgery on 29 October 2015. 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, with the exception of those relating to recruitment checks.
  • 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 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.
  • 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 areas of outstanding practice:

  • 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.

The area where the provider must make improvement is:

  • Review recruitment processes to ensure staff requiring a Disclosure and Barring Service check are in possession of a valid DBS check before commencing 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 are:

  • Review the policy in regard of legionella to ensure risks to staff and patients are effectively managed.
  • Review how governance arrangements are recorded and managed for complaints and risk assessments to ensure current best practice is reflected.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice