Letter from the Chief Inspector of General Practice

We inspected Pendleton Medical centre on 23 October 2014 as part of our new comprehensive inspection programme. This provider had not been inspected before and that was why we included them.

Our inspection team was led by a CQC Inspector and a GP. The team included a practice manager and an expert by experience. We reviewed information provided to us leading up to the inspection and spent seven hours on-site speaking to 12 members of staff and  three patients. We reviewed 34 comment cards which patients had completed leading up to the inspection. From all the evidence gathered during the inspection process we have rated the practice as good

During our inspection the majority of comments from patients were positive about the care and treatment people received. Patients told us they are treated with dignity and respect and involved in making decisions about their treatment options.

A small number of patients reported difficulty in making timely routine appointments with a GP, however they reported where emergency appointments were required these were accommodated on the same day.

Feedback included individual praise of staff for their care and kindness.

Our key findings were as follows:

• Patients said they were treated with compassion, dignity and respect and they were involved in care and treatment decisions.
• Staff understand their responsibilities to raise concerns, and report incidents.
• The practice is clean and well maintained.
• There are a range of qualified staff to meet patients’ needs and keep them safe.
• The practice works with other health and social care providers to achieve the best outcomes for patients.

There were some areas of practice where the provider needs to make improvements. 

Importantly the provider should:

There was no policy and procedures in place for staff to ensure guidance and continuity in relation to consent, or guidance for staff on how to take appropriate action where people did not have the capacity to consent in line with the Mental Capacity Act 2005.

The practice had a system for supervision and appraisal in place for all staff. However we saw staff including the practice manager had not had an appraisal since 2011. 

The practice carried out significant events analysis (SEA) and clinical audits, however there was no system in place to share learning with staff and to review the impact of any changes required in light of the SEA or clinical audit.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection October 2014 – Good)

The key questions 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 Pendleton Medical Centre on 14 June 2018 and 15 June 2018 as part of our inspection programme. We visited the practice twice as key members of staff were unavailable on the original inspection date.

• 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 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’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
• Patients found the appointment system easy to use but some patients told us they could not always get an appointment when phoning the practice at the start of the day and this was confirmed by the GP patient survey results.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• The practice should have an up to date fire risk assessment.

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.