We carried out an announced comprehensive inspection at Easthampstead Surgery on 6 March 2019 as part of our inspection programme.

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 good for all population groups. We found the practice to be good for providing Safe, Effective, Caring and Responsive services. However, we found some governance concerns and have rated the provision of Well led services as requires improvement.

On our inspection, we found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

However, we rated the practice as requires improvement for providing well-led services because:

• Governance arrangements were inconsistent for monitoring of staff training, oversight of recruitment documentation and processes, monitoring of patients being recalled for medication reviews and reducing risk through the undertaking of fire drills.

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.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Review safeguarding training for all staff to take into account guidance published in January 2019.
• Review recall processes to improve uptake for cervical screening.
• Review how minor complaints and patient feedback is captured to add to a review of themes and trends.

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

Letter from the Chief Inspector of General Practice

Our previous comprehensive inspection at Easthampstead Surgery in Bracknell, Berkshire on 11 January 2017 found breaches of regulations relating to the effective and well-led delivery of services. The overall rating for the practice was requires improvement. Specifically, we found the practice to require improvement for the provision of effective and well led services. The practice was rated good for providing safe, caring and responsive services. The concerns identified as requiring improvement affected all patients and all population groups were also rated as requires improvement. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Easthampstead Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 19 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in January 2017. This report covers our findings in relation to those requirements and improvements made since our last inspection.

We found the practice had made improvements since our last inspection. At our inspection on the 19 July 2017 we found the practice was meeting the regulations that had previously been breached. We have amended the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective, caring, responsive and well led services. Overall the practice is now rated as good. All six population groups have also been re-rated following these improvements and are also rated as good.

Our key findings were as follows:

• The practice had implemented new systems to manage, monitor and improve outcomes for patients. We saw evidence which indicated the practices performance to monitor patient outcomes had resulted in a 4% increase in overall performance when compared to the previous year’s performance.

• There was now an overarching governance framework which supported the delivery of good quality care. Improvements had continued to be made after the January 2017 inspection to deliver significant progress in improving services.

• The practice had taken steps to increase the number of patients attending national cancer screening programmes. For example, individual personalised letter encouraging patients to complete national cancer screening programmes and additional awareness training for practice staff with a view to help and support patients make informed choices about the screening programmes.

• Following the review of the practices governance arrangements, we saw the practice now had internal integrated systems which were accurate, valid, reliable and relevant to monitor and manage Easthampstead Surgery.

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 at Easthampstead Surgery in Berkshire on 11 January 2017. Overall the practice is rated as requires improvement. This inspection was a follow-up of our previous comprehensive inspection which took place in April 2016 when we rated the practice as inadequate overall. In particular the practice was rated as inadequate for providing safe, effective and well-led services and requires improvement for providing caring and responsive services. The practice was placed in special measures for six months.

Following the inspection in April 2016 the practice submitted an action plan to Care Quality Commission outlining how they would make the necessary improvements to comply with the regulations.

In January 2017, we found the practice had responded to the concerns raised at the previous inspection and improvements had been made. However, the practice is rated as requires improvement overall as there had been insufficient time since new systems and processes were implemented to evidence that improvements have been embedded and can be maintained.

Specifically the practice is rated as requires improvement for the provision of effective and well-led services and good for provision of safe, caring and responsive services. Our improved rating of requires improvement reflects the positive development of leadership and management systems to deliver significant progress in improving services.

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

• There was an open and transparent approach to safety and an effective system for reporting and recording significant events.

• Significant improvements to risk management had been made and risks to patients were now being assessed and managed.

• The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.

• Staff training had been revised and records demonstrated that staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

• Feedback from patients relating to access to services and the quality of care had improved. This was corroborated by written and verbal feedback collected during the inspection.

• Data showed patient outcomes were lower when compared to local and national averages.

• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Records showed that staff were working with multidisciplinary teams to understand and meet the range and complexity of patients’ needs.

• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.

• The practice had a clear vision that had improvement of service quality and safety as its top priority. The practice fully embraced the need to change, high standards were promoted and there was good evidence of team working. However, as systems were newly implemented there was evidence to show that they were not yet fully embedded and effective.

However, there were areas where the provider must make improvements:

• Continue to review patient outcomes to ensure that patients receive appropriate care and treatment. This would include a review of the system in place when reviewing patients with long term conditions and poor mental health.

• Ensure governance systems are fully embedded and maintained within the practice.

• Ensure the leadership team sustains improvements made to the overall governance of the practice.

The areas where the provider should make improvement are:

• Review the systems in place to promote the benefits of bowel screening in order to increase patient uptake.

• Review the practice computer and internal systems to ensure all documents and correspondence are easily and readily available.

This service was placed in special measures in April 2016. Improvements have been made and Easthampstead Surgery is now rated as requires improvement. I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

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 at Easthampstead Surgery on 14 April 2016. The practice was rated as inadequate for safe, effective and well led services and requires improvement for caring and responsive care. Overall the practice is rated as inadequate.

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

• Staff were not clear about reporting incidents, near misses and concerns and there was no evidence of learning and communication with staff. When incidents and complaints had been identified reviews and investigations were not thorough enough. Patients did not always receive an apology and some incidents had not been identified or escalated.
• Risks to patients were inconsistently assessed and managed, including those relating to fire risk assessments, staffing levels and safeguarding adults.
• Measures to monitor and improve patient outcomes were inconsistent. Limited audits were undertaken to support quality improvement. However, there was no evidence that the practice was comparing its performance to others or sharing learning internally.
• The majority of patients said they were treated with compassion, dignity and respect. However, not all felt cared for, supported and listened to.
• There were no translation facilities and no hearing loop for hearing impaired patients.
• The practice had a number of policies and procedures to govern activity, but some were not localised or lead persons identified. Some documents referred to processes that were not taking place, some were unavailable and some were newly established but not yet implemented or embedded in practice. Many staff were unable to find the policies quickly and easily.
• Appointment systems were not working well so patients found it difficult to access appointments by telephone. Same day appointment requests were dealt with by a telephone triage system that resulted in long delays for call back times.
• The practice had an informal leadership structure, insufficient leadership capacity and limited formal governance arrangements.
• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

The areas where the provider must make improvements are;

• Ensure adult safeguarding policy, processes and procedures are implemented and embedded in practice for all staff.
• Improve the system to identify, capture and manage issues and risk. Review the risk assessment of emergency equipment requirements. Ensure that health and safety policies are in place, regular testing of the fire alarm system and fire drills are documented. Ensure adequate levels of staffing to support the care and treatment of patients
• Implement a formal induction process and improve the monitoring of training to ensure all staff receive training and updates relevant to their role, including safeguarding and basic life support.
• Respond to patient feedback and implement quality improvements to services. Consider changes to the appointment system to ensure this meets patient needs and demand. For example, additional time for complex or enhanced needs such as patients with learning difficulties. Addressing concerns raised regarding the telephone triage system, GPs listening, giving enough time, involving in decisions, explaining tests and treatments, and treating them with care and concern during consultations.
• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision, providing staff with appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.
• Identify and investigate safety incidents and complaints thoroughly and ensure that patients affected receive reasonable support and an apology. Ensure learning and identified areas for improvement is shared with all staff.

In addition the provider should:

• Consider the location of emergency medicines and equipment, so as to be readily available and accessible for all staff. Ensure the GP bag is regularly checked.
• Consider how best to identify and support carers.
• Review recalls and processes for ensuring routine screening rates for patients improves.
• Consider how best to provide a translation service for patients whose first language is not English and how to support patients who are hard of hearing.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During this inspection we spoke to the practice manager and a member of clinical staff. We looked at records and policies. We checked to see if concerns we found during our last inspection had been addressed.

We found that the practice had made changes to its policies on safeguarding vulnerable adults and children. Staff were required to read the policies. Training on safeguarding was provided to staff.

Changes to the recruitment procedure had been made. We reviewed a recently employed staff member’s file which contained the correct information required under the regulations.

All the patients we spoke with were satisfied with the treatment they received from the surgery. Patients told us the surgery provided them with information, advice and discussed treatment with them. One patient said "The doctor is always courteous and listens to me." Another patient said "The GP always explains things clearly." Patients said their privacy and dignity were respected by the service.

Patients were usually able to make appointments when they needed to. The practice recorded patient's medical information appropriately and kept records up to date.

Staff were provided with an understanding of safeguarding and policies to enable them to identify and respond appropriately to abuse.

The provider undertook some, but not all, checks required by law on new staff. GPs registration and eligibility to work was checked.

The practice monitored the quality of its services. Health outcomes, significant events and patient feedback were considered and acted on where appropriate.