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Reports


Review carried out on 9 September 2021

During a monthly review of our data

We carried out a review of the data available to us about PHGH Doctors on 9 September 2021. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about PHGH Doctors, you can give feedback on this service.

Inspection carried out on 20 Novenber and 19 December 2019

During an inspection looking at part of the service

We carried out an inspection at PHGH Doctors on 20 November and 19 December 2019. This was a focussed inspection following our Annual Regulatory Review programme.

The practice was first inspected in September 2015. We rated the practice good for providing an effective, caring, responsive and well led service and requires improvement for providing a safe service. We rated all the population groups as good and the practice as good overall. We found that the provider had breached two regulations of the Health and Social Care Act 2008; Regulation 12(2)g safe care and treatment in regards to medicines management and Regulation 19 fit and proper persons employed resulting from incomplete pre employment checks. We carried out a follow up focussed inspection in November 2016 and found that these issues had been addressed. We rated the practice as good for providing a safe service and good overall.

This inspection focused on the following key questions:

  • Effective
  • Well-led

Because of the assurance received from our review of information we carried forward the ratings for the following key questions:

  • Safe
  • Caring
  • Responsive

At this inspection 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 good for all population groups.

We found that:

  • Patients received effective care and treatment that met their needs.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

  • Continue to look at ways to improve the uptake of the childhood immunisation and cervical 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

Inspection carried out on 23 November 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced focussed inspection at PHGH Doctors on 23 November 2016. We found the practice to be good for providing safe and is rated as good overall.

We had previously conducted an announced comprehensive inspection of the practice on 16 September 2015. As a result of our findings during the visit, the practice was rated as good for being effective, caring, responsive and well led and requires improvement for being safe, which resulted in a rating of good overall. We found that the provider had breached two regulations of the Health and Social Care Act 2008; Regulation 12(2)(g) safe care and treatment in regard to medicines management and Regulation 19(3) (a) (b) fit and proper persons employed resulting from incomplete pre employment checks.

The practice wrote to us to tell us what they would do to make improvements and meet the legal requirements. We undertook this focussed inspection to check that the practice had followed their plan, and to confirm that they had met the legal requirements.

This report only covers our findings in relation to those areas where requirements had not been met. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for PHGH Doctors on our website at http://www.cqc.org.uk/location/1-2124311321.

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

  • Records showed that all staff acting as chaperones had received a Disclosure and Barring service (DBS) check.

  • Recruitment arrangements included all necessary pre-employment checks for all recently employed staff. There was a clear system in place for ensuring all checks were in place prior to employment commencing.

  • There was a system in place to ensure that patient group directions are in place and current for all nursing staff prescribing immunisations or medicines in line with their role.

  • The practice had improved access to GP and nurse led appointments by recruiting two salaried GP’s in early 2016.

  • The practice had responded to the need to provide a more appropriate level of nursing provision by participating in health care assistant apprentice programme. This provided improved availability of nurse led appointments allowing the practice nurse to focus on those patients with more significant need.

  • Arrangements for identifying carers had improved. The practice had identified 25% more carers since the last inspection; an increase from 75.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 16 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at PHGH Doctors on 16th September 2015. 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 to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • 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.
  • 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.

We saw one area of outstanding practice:

  • Palliative patients (those nearing the end of their lives), and their carers, were given access to their GP’s private mobile number to use at any point during a 24 hour period should they need to raise concerns or discuss aspects of care and treatment. This was particularly helpful for the practice’s Jewish population as religious custom dictates that when a patient passes away burial should take place with no undue delays.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider must:

  • Ensure that staff acting as chaperones are appropriately trained and have the required Disclosure and Barring service (DBS) checks.
  • Ensure recruitment arrangements include all necessary pre-employment checks for all staff.
  • Ensure that all patient group directions (PGD’s) are current for all nursing staff prescribing immunisations and vaccinations.

Importantly the provider should:

  • Ensure the appointment system reflects the needs of patients. For example, enabling patients to access an appointment with a preferred GP to provide continuity of care wherever possible.
  • Improve the availability of nurse led appointments.
  • Ensure there are appropriate levels of nursing provision to meet the needs of patient
  • Increase the number of identified carers to 10% of the patient population in order to better support patients in managing their care and treatment.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice