The Care Quality Commission
  • Doctor
  • GP practice

Archived: Pencester Health

Overall: Good read more about inspection ratings

Dover Health Centre, Maison Dieu Road, Dover, CT16 1RH (01304) 865577

Provided and run by:
Pencester Surgery

All Inspections

21 March 2020

During an annual regulatory review

We reviewed the information available to us about Pencester Health on 21 March 2020. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

20/11/2018

During a routine inspection

This practice is rated as Good overall. (Previous rating of requires improvement April 2018).

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Pencester Health on 20 November 2018. The inspection was conducted to follow up on areas identified in their earlier inspection as requiring improvement. The inspection conducted in April 2018 found improvements were required to ensure safe care and treatment and effective systems and processes were in place for good governance.

At this inspection we found:

  • 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.
  • We found staff had received training on sepsis and on safeguarding children and vulnerable adults.
  • Medicine alerts were being reviewed, actioned and followed up in an appropriate manner
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence - based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a commitment to continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Continue to identify and support carers.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

25/04/2018

During a routine inspection

This practice is rated as requires improvement overall. (Previous inspection 22 July 2015 – Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced inspection at Pencester Surgery on 18 April 2018 as part of our inspection programme.

At this inspection we found:

  • The practice did not have effective systems to manage risk so that safety incidents were less likely to happen.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • The GP partners took over another surgery Dover Medical Practice, now known as Pencester Health Centre and most of the staff work across both locations.
  • During the course of the inspection we found that some maternity and midwifery activities were taking place. The practice was not registered with the Care Quality Commission (CQC) to deliver these services from this location. We informed them of this situation and they have sent us evidence that have applied to add this regulated activity to their CQC registration.

We saw one area of outstanding practice:

  • The practice collaborated with a local translation service to provide a translator at Pencester Health on a daily basis. Patients from both practices had access to the translator who provided telephone or face to face support to patients whose first language was not English. The practice had worked with other organisations to facilitate this service in response to a high need for a translation service within their practice population.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Review and improve the reception protocols to include the management of patients with sepsis symptoms.
  • Continue to develop the system for inviting and following up childhood immunisations invitations in order to meet national targets.
  • Review and improve staff training to help ensure all staff members remain up to date with essential training.
  • Embed the new system for supporting the family of recently bereaved patients.
  • Review and improve the complaints system to include verbal complaints in order to help identify trends and change practice.
  • Review and improve how patients from Pencester Health are represented within the patient participation group (PPG) to help ensure their views are captured.
  • Review and improve how the duty of candour conversations are recorded in significant events.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

22 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pencester Health on 22 July 2015. Overall the practice is rated as good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • 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.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • 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.

We saw one area of outstanding practice:

  • The practice worked closely with the local translation team on a daily basis in contacting patients and arranging referrals and follow up health assessments. A member of the translation team would stay at the practice to chaperone and assist the patient throughout their consultation or treatment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

21 August 2013

During a routine inspection

We spoke with five people who used the service, this included one active member of the Patient Participation Group (PPG), and with clinical and non-clinical staff.

People we spoke with were generally positive about the service. They said that it was not a problem to obtain an appointment. They said that both the clinical and reception staff were friendly and polite. One person told us 'My opinion of the service is very good.' Another said 'The staff are approachable, they are helpful.' People said that during consultations the doctors explained issues and answered questions in a way they could understand. People told us that they were generally happy with the time allowed for consultations.

People received care that ensured their safety and welfare. People were assessed and care was provided to meet their individual needs. Diagnostic tests were carried out if necessary and appropriately followed up.

There were good infection control practices in place. The service was clean and tidy and people told us the practice was always clean. One person told us 'It's always like this when I attend, really clean.'

Processes around recruiting and monitoring staff were not robust. Personnel records were incomplete.

The practice monitored the quality of the service by performing audits and seeking the views of the patients by surveys and engagement in the Patient Participation Group (PPG).