The Care Quality Commission
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Penn Manor Medical Practice

Overall: Good read more about inspection ratings

Manor Road, Penn, Wolverhampton, West Midlands, WV4 5PY (01902) 575142

Provided and run by:
The Royal Wolverhampton NHS Trust

Important: The provider of this service changed. See old profile

All Inspections

Other CQC inspections of services

Community & mental health inspection reports for Penn Manor Medical Practice can be found at The Royal Wolverhampton NHS Trust. Each report covers findings for one service across multiple locations
Read inspection report

28 July 2021

During an inspection looking at part of the service

We carried out a desk based announced inspection review at Penn Manor Medical Practice on 27 and 28 July 2021. Overall, the practice is rated as good.

Ratings for each key question:

Safe – Good

Effective – Good (rating carried forward from March 2020 inspection)

Caring – Good (rating carried forward from March 2020 inspection)

Responsive – Good (rating carried forward from March 2020 inspection)

Well Led – Good (rating carried forward from March 2020 inspection)

Penn Manor Medical Practice was previously inspected in March 2020 and rated good overall and for all population groups. However, the practice was rated as requires improvement for providing safe services.

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

Why we carried out this review

This inspection was a focused review of information to follow up on:

  • The key question of Safe, which was rated as requires improvement at the last inspection in March 2020.
  • Breaches of regulations and ‘shoulds’ identified at the previous inspection. The main issues we identified were related to the management of medicines.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our reviews differently.

This inspection was carried out in a way which enabled us to not have to undertake an onsite visit. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing / telephone
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from 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 have rated this practice as Good overall and good for all population groups

We found that:

  • The practice had made sufficient improvement to introduce and embed effective systems for the prescribing and monitoring of all patients prescribed high-risk medicines.
  • We found that formal processes for the supervision of the prescribing and clinical practices of advanced nurse practitioners were in place.
  • The management of medicines at the practice was supported by the Deputy Clinical Director of Pharmacy for the Royal Wolverhampton NHS Trust (RWT). The pharmacy clinical director had oversight of the RWT primary care network group of GP practices.

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

  • Continue to improve the monitoring and review of patients prescribed high risk medicines.
  • Continue to monitor and reassure themselves that clinicians are following the procedures and guidance in place for the review of patients prescribed high risk medicines

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

5 March 2020

During an inspection looking at part of the service

We carried out an announced focused inspection at Penn Manor Medical Practice on 5 March 2020. This inspection looked at the following key question (Safe). The service was previously inspected in January 2019 and was rated requires improvement in safe and good overall. The report on the January 2019 inspection can be found by selecting the ‘all reports’ link for Penn Manor Medical Practice on our website at www.cqc.org.uk .

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.

The practice remains rated as good overall.

Because of the assurance received from our review of information we carried forward the ratings for providing effective, caring, responsive and well led services. The practice remained rated as requires improvement for providing safe services because:

  • The practice had not made sufficient improvement to introduce and embed effective systems for the prescribing and monitoring of all patients prescribed high-risk medicines.
  • We found that formal processes for the supervision of the prescribing and clinical practices of advanced nurse practitioners were not in place.
  • We found that the practice did not stock all the recommended emergency medicines.

We found that:

  • Recruitment practices were reviewed to ensure that all the documents to confirm appropriate recruitment checks had been carried out were available in staff files and support evidence that safe recruitment practices are followed.
  • New electronic patient specific directions templates were introduced. These were completed electronically and signed by the GP prior to the administration of the prescribed medicine.
  • The practice had continued to identify carers and establish what support they need. The number of carers on the practice register had increased from 31 (0.3%) to 264 (2.3%) carers.
  • The practice had reviewed the processes and systems in place to ensure complaints, incidents or events are correctly classified.

The areas where the provider must make improvements are:

  • Care and treatment must be provided in a safe way for service users.

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

15 January 2019

During a routine inspection

We carried out an announced comprehensive inspection at Penn Manor Medical practice on 15 January 2019 as part of our inspection programme.

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 rated the practice as requires improvement for providing safe services because:

  • The practice could not demonstrate that patients’ health in relation to the use of high risk medicines was always appropriately monitored or that a clinical review was carried out before issuing repeat prescriptions.
  • The practice had not ensured that Patient Specific Directions (PSD) were completed and signed by a GP prior to administration by designated staff.
  • The practice could not demonstrate that safe recruitment practices were completed for all staff.

We found that:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

The areas where the provider must make improvements are:

  • Care and treatment must be provided in a safe way for service users.

The areas where the provider should make improvements are:

  • Ensure patient specific directions are completed and signed by the GP prior to the administration of the prescribed medicine.
  • Ensure all staff files, which include locums and agency staff have references to support evidence that safe recruitment practices are followed.
  • Continue to identify carers and establish what support they need.
  • Ensure that systems are in place to clearly identify complaints that should be classified as a significant or missed event.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice