Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pencester Health on 22 July 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.
• 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.
• Patients said they found it easy to make an appointment with a named GP and that 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.

We saw one area of outstanding practice:

• The practice worked closely with the local translation team on a daily basis in contacting patients and arranging referrals and follow up health assessments. A member of the translation team would stay at the practice to chaperone and assist the patient throughout their consultation or treatment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We spoke with five people who used the service, this included one active member of the Patient Participation Group (PPG), and with clinical and non-clinical staff.

People we spoke with were generally positive about the service. They said that it was not a problem to obtain an appointment. They said that both the clinical and reception staff were friendly and polite. One person told us “My opinion of the service is very good.” Another said “The staff are approachable, they are helpful.” People said that during consultations the doctors explained issues and answered questions in a way they could understand. People told us that they were generally happy with the time allowed for consultations.

People received care that ensured their safety and welfare. People were assessed and care was provided to meet their individual needs. Diagnostic tests were carried out if necessary and appropriately followed up.

There were good infection control practices in place. The service was clean and tidy and people told us the practice was always clean. One person told us “It’s always like this when I attend, really clean.”

Processes around recruiting and monitoring staff were not robust. Personnel records were incomplete.

The practice monitored the quality of the service by performing audits and seeking the views of the patients by surveys and engagement in the Patient Participation Group (PPG).

This practice is rated as Good overall. (Previous rating of requires improvement April 2018).

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Pencester Health on 20 November 2018. The inspection was conducted to follow up on areas identified in their earlier inspection as requiring improvement. The inspection conducted in April 2018 found improvements were required to ensure safe care and treatment and effective systems and processes were in place for good governance.

At this inspection we found:

• 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.
• We found staff had received training on sepsis and on safeguarding children and vulnerable adults.
• Medicine alerts were being reviewed, actioned and followed up in an appropriate manner
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence - based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a commitment to continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Continue to identify and support carers.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.