Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Theale Medical Centre on 15 & 24 March 2017. The overall rating for the practice was requires improvement. Specifically, the practice was found to be requires improvement for safe and well led services and good for providing effective, caring and responsive services. The full comprehensive report on the March 2017 inspection can be found by selecting the ‘all reports’ link for Theale Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 25 October 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 March 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Our key findings were as follows:

• The practice had reviewed and updated their governance processes to ensure risks were identified and resolutions implemented quickly and consistently. Active monitoring procedures were in place to mitigate risks.
• Practice staff told us communication between practice management and non-clinical staff had improved and they felt more supported and involved in decisions about how the practice was run.
• Staff had been made aware of up to date policies and procedures. Staff had appropriate knowledge demonstrating the practice policies were embedded.
• Governance arrangements for recruitment checks, staff training and dispensary processes had improved.
• The practice had reviewed the governance arrangements for dealing with verbal complaints. The complaints log demonstrated verbal complaints were dealt with in timely way and were regularly reviewed to ensure actions had been taken.
• An action plan for infection control audit outcomes had been documented to ensure actions had been completed.
• The practice had encouraged patients on the learning disability register to attend for health checks and had improved the number of patients receiving these.

At our follow up inspection the practice was rated as good for safe and well led services. The population groups have also been rated good. Overall the practice is now rated as good.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Our previous inspection in November 2014 found breaches of regulations relating to the safe delivery of services.

We found the practice required improvement for the provision of safe services, and was rated good for providing effective, caring, responsive and well-led services. The population groups were rated as good for the patients registered at the practice.

This inspection was undertaken to check the practice was meeting regulations. For this reason we have only rated the location for the key questions to which these relate. This report should be read in conjunction with the full inspection report of 26 November 2014.

We found the practice had made improvements since our last inspection. At our inspection on the 30 September 2015 we found the practice was meeting the regulations that had previously been breached.

Specifically we found:

• Improvements had been made to maintain the accurate records of patients information. For example home visits had been properly recorded to ensure other staff would be able to access an accurate record of patients most recent care and treatment.
• The practice had instituted systems to manage medicines and nomad or blister packs were checked by a second member of staff.
• Staff were complying with the practice control of infection policy.
• The practice was actively identifying, assessing and managing risks to health and safety of patients, staff and visitors.

We have amended the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Theale Medical Centre is located in purpose built premises in West Reading. There are approximately 10,700 patients registered at the practice. We carried out an announced comprehensive inspection of the practice on 26 November 2014 and we visited Theale Medical Centre. This was the first inspection of the practice since registration with the CQC. There is a branch practice called Calcot Surgery, 72a Royal Avenue, Calcot, Reading, RG31 4UR which we did not visit as part of this inspection.

Theale Medical Centre is a purpose built. Adaptations have been made to ensure the practice is accessible. The local community has areas of deprivation and the staff were aware of the needs of this section of the population. The appointment system allows advanced appointments to be booked. Urgent appointment slots were also available. Patients told us they were able to make appointments when they needed them, although some patients told us they needed to wait too long for an appointment. Patients told us staff were caring, friendly and considerate.

We spoke with nine patients during the inspection. We met the chair person of the Patient Participation Group, five GP’s the practice manager, reception manager, one member of the nursing team and administration staff.

Theale Medical Centre practice was rated good overall.

Our key findings were as follows:

The practice mostly maintained a safe environment but there were concerns about the management of medicines and staff recruitment. Patients with health conditions were well cared for and national data placed the practice above the national average for caring for long term conditions. Some elements of patient records were not always completed to ensure safety in the delivery of their care. Patients told us the practice was caring, accessible and they felt well supported. The practice was in a state of transition where processes and procedures were being changed. The leadership were proactive in assessing and planning for future demands on the practice.

However, there were also areas of practice where the provider must make improvements.

The provider must:

• ensure policies, procedures and monitoring tools such as safeguarding policies, training records and infection control tools are consistent, suitable for their purpose and accessible.
• amend and monitor the processes for dispensing and storing medicines.
• implement a fire risk assessment for all the practice’s premises

We have issued compliance actions for Management of Medicines and Assessing and Monitoring the Quality of Service provision.

In addition the provider should:

-monitor the use of cleaning equipment to ensure it is used in designated areas of the practice.

- undertake a legionella risk assessment to determine what action may be required to reduce any risk of infection

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 27 February and 5 March 2019 as part of our inspection programme. The practice was previously inspected in March 2017, with an overall rating of requires improvement, as safe and well-led were rated as requires improvement. A follow up inspection was undertaken in October 2017 and the practice was rated as good overall.

Our judgement of the quality of care at this service is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about the service and information from the provider, patients, the public and other organisations.

The practice is rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Inadequate

This practice is rated as requires improvement overall.

We concluded that:

• The practice had clear systems, practices and processes to keep people safeguarded from abuse.
• Patients were supported, treated with dignity and respect and were involved as partners in their care.

However, we also found that:

• The practice did not always have systems to keep people safe.
• People’s needs were not always met by the way in which services were organised and delivered.
• The delivery of high quality care was not always assured by effective governance procedures.

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 are:

• Ensure systems for monitoring cervical screening outcomes are fully embedded and effective.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice