Background to this inspection
Updated
13 March 2020
The Berkshire Medical Practice is located in a purpose-built building in Maidenhead, Berkshire. It shares the building with an NHS GP service and has its own waiting room and clinical room. Services are provided by The Berkshire Medical Practice Ltd.
The service is registered with the CQC to provide the regulated activities Diagnostic and screening procedures and Treatment of disease, disorder or injury.
All services and regulated activities are carried out from:
Symons Medical Centre Building
1st Floor Suite
25 All Saints Avenue
Maidenhead
SL6 6EL
Patients can access services by calling the telephone number between 8am and 2pm Monday to Friday or by contacting a dedicated mobile telephone number at other times. Patients can also access service information and make appointments through the website:
The service has core opening hours of 7am to 7pm and patients can book appointments at other times by prior arrangement. The service is not required to provide out of hours services and patients are advised to contact their NHS GP out of hours provider if required. However, the service states they will arrange out of core hours appointments by request, including evenings up to 11pm and weekends.
During this inspection we interviewed two of the three GPs, reviewed service documents and patient records and received written feedback from patients.
To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:
- Is it safe?
- Is it effective?
- Is it caring?
- Is it responsive to people’s needs?
- Is it well-led?
These questions therefore formed the framework for the areas we looked at during the inspection.
Updated
13 March 2020
We carried out an announced comprehensive inspection at The Berkshire Medical Practice on 4 February 2020 to follow up on a breach of regulation and to provide ratings for all key questions.
Care Quality Commission (CQC) inspected the service on 23 January 2019 and asked the provider to make improvements because although the care being provided was safe, effective, caring and responsive, it was not being provided in accordance with the relevant regulations relating to well-led care. Specifically, we found the provider had breached Regulation 17 (good governance) of the Health and Social Care Act 2008. This was because there were governance concerns over identifying and responding to risk, there was an absence of a system to monitor staff training requirements, there was no established programme of quality improvement activity and patient feedback had not been recorded or documented.
We checked these areas as part of this comprehensive inspection and found this had been resolved.
The Berkshire Medical Practice is a private GP service located in Maidenhead, Berkshire. They offer a variety of services including GP appointments, long term conditions management and monitoring, travel vaccinations, health checks/health screening and maternity care.
This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Berkshire Medical Practice provides a range of non-surgical cosmetic interventions, for example anti-wrinkle treatments and Botox injections which are not within CQC scope of registration. In addition, they offer joint injections which is also not within CQC scope of registration. Therefore, we did not inspect or report on these services.
There are three GPs who founded the service and are jointly responsible for the day-to-day running and organisation of the service. All three GPs are the CQC registered managers. A registered manager is a person who is registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
As part of our inspection we asked for CQC comments cards to be completed by patients prior to our inspection. We received four cards which were all positive about the services provided, GPs and standard of care they received. There were no patients available to speak with during the inspection day.
Our key findings were:
- The service had clear systems to keep people safe and safeguarded from abuse.
- There were systems and processes in place to manage risk.
- When incidents did occur, the service learned from them and improved their processes.
- The service ensured that care and treatment was delivered according to evidence based research or guidelines.
- The service introduced a system to review and monitor the essential training needs of all GPs and could demonstrate all GPs had up to date training.
- There was a focus on quality improvement activity and we saw two clinical audits which demonstrated actions taken to improve quality.
- The service encouraged and monitored patient feedback with the introduction of an annual patient survey and by monitoring online reviews. Patient comment cards, online reviews and the provider patient survey were positive about the care and treatment provided at the service.
- The culture of the service encouraged candour, openness and honesty.
- There were effective systems and governance processes in place to identify and respond to risk.
The area where the provider should make improvements is:
- Consider implementing a system to document verbal compliments to further improve monitoring of patient feedback.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care