We carried out an announced focused inspection of Datchet Health Centre on 5 June 2019 to follow up on a breach of regulation found during a comprehensive inspection in May 2018.

Prior to this inspection we carried out an annual regulatory review (ARR) to determine if there had been any significant changes in the quality of patient care since the last inspection. The ARR identified no concerns or changes in quality and we therefore made the decision to follow up on the breach of regulation only at this inspection

This inspection looked at the following key question:

• Well Led

To make our judgement we spoke with the deputy practice manager, two members of the reception and administration team and reviewed documents relating to the governance of the service.

We have rated this practice as good for providing Well led services.

We found that:

• Governance arrangements had been reviewed to ensure staff training was effectively monitored and staff remained up to date with essential training.
• The practice had reviewed fire safety risks and carried out a fire drill in January 2019. There was a programme of future fire drills planned.
• The practice had reviewed their complaints processes to identify where there were gaps in acknowledgement timescales and escalation to external stakeholders.
• The health status of new staff had been reviewed to identify any reasonable adjustments.

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

This practice is rated as Good overall. (Previous inspection April 2016 – Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Datchet Health Centre on 16 May 2018. We undertook this inspection as part of our inspection programme and in response to concerns.

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.
• Fire safety risk required a review to ensure fire drills were undertaken at suitable intervals.
• 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.
• Arrangements for monitoring staff training was inconsistent and had not ensured all staff received the required training in health and safety, fire safety or mental capacity act.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• The practice had reviewed the appointment system and had introduced changes to staffing to facilitate more appropriate allocation of appointments.
• Many patients reported that they were able to access care when they needed it.
• Complaints were taken seriously and thoroughly investigated to identify learning outcomes.
• There was a clear governance structure in place, although we found some examples where these had been inconsistently applied.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements are:

• 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:

• Review recruitment procedures to include a formal health status of employees and ensure all staff have equal access to reasonable adjustments (where necessary).

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

In March 2015, we found concerns related to the access of the service for working age patients during a comprehensive inspection of Datchet Health Centre, Berkshire. The service was rated as good overall with a requires improvement rating in the population group for working age people (including those recently retired and students).

Following the inspection the provider sent us evidence detailing of how they would improve the areas of concern that related to this population group.

We carried out a desktop focussed inspection at Datchet Health Centre in April 2016. This inspection was to follow up on concerns that the appointment system did not offer sufficient flexibility to offer appropriate access to the working age population group.

Following the improvements made since our last inspection in March 2015; the practice now offers extended hours appointments during the early morning and evening on Monday, Wednesday, Thursday and Friday. Telephone consultations were also available and patients had access to an extended hours service from 6.30pm at another location in Windsor, which was 10 minutes away.

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 of Datchet Health Centre, 4 Green Lane

Slough, Berkshire, SL3 9EX on 25 March 2015. This was the first inspection undertaken at the practice.

Overall the practice is rated as good. However, the practice should make some improvements to ensure consistent standards of cleanliness are achieved and review the availability on three days of the week of appointments for patients who work.

GPs and management at the practice were aware of the views of the registered patients and responded to feedback from patients. A recent survey showed that the number of patients who would recommend the practice to others had increased by 10% in one year.

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.

• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group (PPG).

• The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand
• The practice had a clear vision which had quality and safety as its top priority. High standards were promoted and owned by all practice staff with evidence of team working across all roles.
• The practice recognised any weaknesses in the way services were delivered and implemented action to make improvements.

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

The provider should::

• Ensure appropriate cleaning standards are consistently achieved. A legionella risk assessment must be put in place with relevant control measures to reduce the risk of legionella being identified.
• Further review the availability of appointments that are accessible to patients who work.

• Retain all documentation relating to pre-employment checks.
• Clarify their audit plan to formalise the number of completed audit cycles that identify and address areas of clinical performance that could be improved.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We reviewed the information available to us about Datchet Health Centre on 16 May 2019. 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.