Letter from the Chief Inspector of General Practice

We carried out an announced focussed inspection at Penshurst Gardens Surgery on 2 February 2017. We found the practice to be good for providing safe services and it is rated as good overall.

We previously conducted an announced comprehensive inspection of the practice on 13 April 2016. As a result of our findings, the practice was rated as good for being responsive, effective, caring and well led; and rated as requires improvement for being safe which resulted in a rating of good overall. We found that the absence of a recent fire risk assessment and of a Legionella water temperature monitoring regime had breached Regulation 12 HSCA (RA) Regulations 2014 (Safe care and treatment) of the Health and Social Care Act 2008.

The practice wrote to us to tell us what they would do to make improvements and meet the legal requirements. We undertook this focussed inspection to check that the practice had followed their plan, and to confirm that they had met the legal requirements.

This report only covers our findings in relation to those areas where requirements had not been met. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Penshurst Gardens Surgery on our website at http://www.cqc.org.uk/location/ 1-540418399 .

Our key findings across all the areas we inspected were as follows:

• The practice had introduced a new fire safety policy and we saw that, in accordance with the policy, six monthly fire drills and weekly fire alarm tests were taking place. We also saw that an annual fire risk assessment had taken place.

• The practice had recently commissioned a Legionella risk assessment and management plan; and we saw that, in accordance with assessment, a monthly water temperature monitoring regime had been introduced. We also noted that the practice manager and a partner GP had received legionella awareness training and that a Legionella policy had been introduced.

• The systems introduced since our last inspection in April 2016 enabled the provider to manage risk and provide a current picture of safety.

• At this inspection we also noted that the practice had made improvements to aspects of care highlighted in our April 2016 report which, although not breaching Regulations were listed as areas where the practice could improve.

• For example, we noted that the practice had introduced weekly checks of its emergency medical equipment and that a new protocol had been introduced for monitoring and actioning incoming scanned correspondence. The practice had also improved its systems for identifying and providing support to carers. For example, records showed that the percentage of patients identified as carers had increased from 1% to 2%.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Penshurst Gardens Surgery on 13 April 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

• Risks to patients were assessed and well managed with the exception of those relating to fire safety and systems for actioning incoming correspondence.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

• 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. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients spoke positively about the ease of making an appointment with a named GP and there was continuity of care with urgent appointments available the same day.
• GP patient survey feedback was lower than local and national averages regarding phone access but the practice highlighted actions being taken to improve access.
• 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.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Ensure that annual fire risk assessments take place.

• Introduce a monthly temperature monitoring regime in accordance with the recommendations of a February 2014 Legionella risk assessment; and ensure that subsequent assessments take place in accordance with recommended guidance.

• Ensure that the system in place for actioning and monitoring incoming correspondence is appropriate to keep people safe.

The areas where the provider should make improvement are:

• Introduce a system for routinely checking its emergency oxygen cylinder.

• Introduce a system for checking phone access availability, so as to assess the impact of recent changes.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice