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