We carried out a review of the data available to us about Penshurst Gardens Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Penshurst Gardens Surgery, you can give feedback on this service.
OVERALL SUMMARY
We carried out an announced inspection at Penshurst Gardens Surgery on 20 July 2021. All key questions were rated as good apart from ‘responsive’ which we have rated as requirements improvement due to significantly low patient feedback around access to the service. Overall, the practice is rated as Good.
Safe - Good
Effective - Good
Caring - Good
Responsive – Requires Improvement
Well-led - Good
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Penshurst Gardens Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
On 20 July 2021 we conducted a comprehensive inspection to follow up on concerns that were brought to our attention. We found no evidence to support those concerns during this inspection.
We previously inspected the practice in February 2017, the practice was rated good at that time.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently. This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements. This included:
Our findings
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 for all population groups. We found that:
Whilst we found no breaches of regulations, the provider should:
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP Chief Inspector of Primary Medical Services and Integrated Care
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%.
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:
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.
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.
Chief Inspector of General Practice