Pennfields Health Centre

We carried out an announced inspection at Pennfields Health Centre. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive – Good

Well-led – Requires Improvement

This was the first visit to Pennfields Health Centre following its registration with a new provider, Health and Beyond Ltd. in September 2019.

Why we carried out this inspection

This inspection was a comprehensive inspection to review the Health and Beyond group of services. This inspection was also planned to follow up on whistleblowing concerns we received and concerns raised by patients relating to access.

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:

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• Site visit.
• The inspections of the Health and Beyond Ltd. GP practices took place over a period of three months to provide time to follow up on the whistleblowing concerns received prior to and during the inspection process.

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

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm. Staff were aware of systems and processes to follow if they had any concerns.
• The partnership learned from incidents, events and complaints and ensured learning was shared among the staff team.
• Health and Beyond Ltd. had made effective use of its multiple practice sites and had made adaptations to minimise the risks to patients and staff during COVID-19.
• We found the premises were well maintained, appeared clean and tidy and had appropriate infection prevention and control arrangements in place.
• The practice also provided walk in services to increase patient access to appointments.
• Our clinical searches found patients medicines were mostly safely managed.
• The practice was supported by a pharmacy team who carried out regular audits to further support the safety of medicines prescribed.
• Advanced practitioners and GP locums were employed at the practice on a temporary contract basis to support the walk in appointment system.
• Patients received effective care and treatment that met their needs. Our review of clinical records found effective systems were in place for the follow up and monitoring of patients with long term conditions.
• A significant number of patients reported difficulties accessing care and treatment in a timely way at this practice. The partnership and management team were aware of these concerns and plans were in place to address them.
• It was not evident that leadership arrangements could demonstrate an open culture in which staff felt engaged and enabled to raise concerns.

Whilst we found no breaches of regulations, the provider should:

• Continue to develop centralised HR information so that it provides clear and accurate staff information for management and monitoring purposes.
• Continue to develop and improve the induction and recruitment processes and documentation.
• Provide evidence that staff vaccination and immunity for potential health care acquired infections are recorded or risk assessed for all staff.
• Continue to proactively identify carers so that they can be supported to access services available to them.
• Improve the uptake of childhood immunisations and cervical cancer screening.
• Continue to implement and monitor the action plan to improve access for patients and monitor the impact of the changes.
• Continue to implement and monitor the action planned to improve the staff working environment, communication arrangements with all staff groups and demonstrate an open culture in which staff felt engaged and enabled to raise concerns.

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