Archived: Penn Manor Medical Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Penn Manor Medical Centre on 5 May 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to be inadequate in safe, and requires improvement for providing effective, responsive and well led services. It was rated good for providing caring and services. The concerns we identified in the safe, effective, responsive and well-led domains relate to everyone who uses the practice including the population groups. Therefore all the population groups we inspected were rated as requires improvement.

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
• Risks to patients were assessed and reasonably well managed, with the exception of those relating to recruitment checks.
• Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
• Patients’ needs were assessed and care was planned, although best practice guidance was not always followed. Staff had received training appropriate to their roles.
• Patients said they were treated with 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 told us when they contacted the practice they could request to speak with their preferred GP for a telephone consultation. All patients were offered a telephone consultation and appointments were made as required. Same day appointments were available with the GP registrars.
• There was a clear leadership structure and staff felt supported by management.
• The practice did not proactively seek feedback from patients.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure that all necessary pre-employment checks are obtained and appropriate evidence kept on file.
• Ensure that Patient Group Directives (PGDs) are up to date and signed by both the GP and nursing staff.
• Ensure there are systems in place to assess, monitor and improve the quality and safety of the service. For example the use audits, risk assessments and surveys.

In addition the provider should:

• Ensure the methods used to review and disseminate learning from significant events and near misses are robust.
• Provide staff with up to date infection prevention and control training.
• Ensure all staff understand the Mental Capacity Act 2005 and implications for their practice.
• Review how confidentiality is maintained at the reception and prescription desks, by both staff and visitors to the practice.
• Promote the availability of interpreter services.
• Ensure all staff are aware of and can identify with the practice mission statement and values.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice