The Care Quality Commission
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  • GP practice

Pershore Medical Practice

Overall: Good read more about inspection ratings

Queen Elizabeth House, Queen Elizabeth Drive, Pershore, Worcestershire, WR10 1PX (01386) 553346

Provided and run by:
Pershore Medical Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Pershore Medical Practice on 6 July 2023. 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 Pershore Medical Practice, you can give feedback on this service.

21 September 2022

During an inspection looking at part of the service

We carried out an announced comprehensive at Pershore Medical Practice on 21 September 2022. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

Following our previous inspection on 17 September 2015, the practice was rated outstanding overall and specifically for the key questions of effective and responsive. Safe, caring and well led were rated as good.

At the last inspection we rated the practice as outstanding for providing effective and responsive services because:

  • The practice was outstanding at providing services for people with long term conditions and people in vulnerable circumstances. The practice was good at providing services for older people, families, children and young people, the working age population and those recently retired and people experiencing poor mental health.

At this inspection, we found that those areas previously regarded as outstanding practice were now embedded throughout the majority of GP practices. The practice is therefore now rated good for providing effective and responsive services.

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

Why we carried out this inspection

We carried out this inspection as part of our ongoing monitoring following up on the previous comprehensive inspection. Therefore, as part of this comprehensive inspection we inspected all five key questions: safe, effective, caring, responsive and well-led. This inspection included a comprehensive review of information and a site visit where we inspected safe, effective, responsive and well-led care. Additionally, we reviewed access to the practice via telephone and a patient’s ability to book in with a named GP.

How we carried out the inspection/review

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently. Therefore, as part of this inspection we completed clinical searches on the practice’s patient records system and discussed the findings with the provider. This was with consent from the provider and in line with all data protection and information governance requirements.

The inspection also included:

  • Requesting and reviewing evidence and information from the service
  • A site visit
  • Conducting staff interviews
  • Reviewing patient records to identify issues and clarify actions taken by the provider

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 actively involved in initiatives used to identify patients with high cholesterol enabling the practice to treat their conditions more effectively.
  • We found that systems were in place to support and share access information with other services to support the care and treatment of patients with learning disabilities.
  • The practice was providing support to people to use equipment at home and were using children’s heel prick tests to identify parents who may have undiagnosed high levels of cholesterol.
  • Staff were consistent and proactive in helping patients to live healthier lives.
  • Staff treated patients with kindness, respect and compassion. Feedback from patients was positive about the way staff treated people.
  • The practice consistently reviewed and improved the way people were able to access care and treatment.
  • The practice had a culture good quality sustainable care.
  • The practice had systems, practices and processes to keep people safe and safeguarded from abuse however these were not always effective. In particular, we found that disclosure and barring service (DBS) checks were not routinely being carried out as part of the recruitment process. Following our inspection the practice demonstrated that they had obtained evidence of DBS checks from staff members’ previous employers.

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

  • Strengthen monitoring systems to ensure staff have the skills, knowledge and experience to carry out their roles.
  • Establish systems to demonstrate that clinical supervision is being carried out
  • Continue taking action to improve uptake of childhood immunisations and cervical cancer screening
  • Continue to strengthen recruitment systems to ensure staff are suitable for their role and safe for deployment within the practice.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

19 May 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We inspected this service on 19 May 2015 as part of our new comprehensive inspection programme.

The overall rating for this service is outstanding. We found the practice to be good for providing safe, caring and well led services and outstanding for providing effective and responsive services.

The practice was outstanding at providing services for people with long term conditions and people in vulnerable circumstances. The practice was good at providing services for older people, families, children and young people, the working age population and those recently retired and people experiencing poor mental health.

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from incidents were maximised.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.
  • There were systems in place to keep patients safe from the risk and spread of infection.
  • 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, with easy read information available for people with a learning disability to use should they prefer.
  • The practice held regular multidisciplinary clinical team meetings to discuss the needs of complex patients, for example those with end of life care needs or children who were at risk of harm.
  • The practice had a clear vision which had quality and safety as its top priority. High standards were promoted and owned by all practice staff with evidence of team working across all roles.
  • The practice had an open culture that was effective and encouraged staff to share their views through staff meetings and significant event meetings.

We saw several areas of outstanding practice including:

  • Two new staff roles had been created (as part of a CCG led initiative utilising Avoiding Unplanned Admissions enhanced service funding) for patients in the community, a Care Home Advanced Nurse Practitioner (ANP) and a Community ANP. The care home ANP worked to reduce unplanned hospital admissions. This role was created 12 months ago and we saw evidence of the positive impact this had had for patients. As a result of this the practice has utilised funding to make this role a full time position. The community ANP arranged phone calls and or visits to frail and elderly patients, including those who were recently discharged from hospital, to assess their needs and offer support. This service, introduced in April 2015 has provided patients with health assessment, medical care and support within their home.
  • The practice worked with the Worcestershire Alliance Board in partnership between Worcestershire Health and Care NHS Trust and South Worcestershire Healthcare as part of a Pro-Active Care Team (PACT). This team cared specifically for those patients who were on the unplanned admissions register to avoid further unplanned admissions to hospitals. Nationally reported data showed that the practice performed well against indicators relating to unplanned admissions. For the year ended March 2014 Pershore Medical Practice were 2% lower than the national average for admissions.
  • A range of services were provided by the practice to meet the needs of patients with long term conditions. Three practice nurses were specifically trained in the management of diabetes care and this included a commitment to the Diabetic Expert Patient Programme which educated patients to manage their conditions. The practice was one of the highest performing practices in South Worcestershire for the care for diabetic patients. There was a high uptake of flu vaccines (99%) and foot examinations (93%) for diabetic patients.
  • Pershore Medical Practice had looked for innovative ways to develop services for patients in their area. They had developed a project led by the practice manager at the practice, and initiated a meeting with two other local practices in the Pershore area. They had sought agreement to work together as a local cluster on a range of projects. The projects included shared skills and expertise and also involved working with members of the CCG and Age UK. As a result of this they had developed a shared referral process with another local practice where skills and expertise were made available to all patients at both practices. For example, one of the GPs provided a secondary Ear, Nose and Throat (ENT) service for both Pershore practices, principally dealing with ear infections and wax clearance where syringing may cause harm to the patient. The practice told us this provided a fast, flexible and local service as an alternative to hospital visits that ensured a better outcome for patients as they were able to access this service locally and promptly. The practice looked to extend these services for patients early in 2015.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice