10 November 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Radnor House Surgery and Ascot Medical Centre on 10 November 2016. This comprehensive inspection was carried out to check that the practice was meeting the regulations and to consider whether sufficient improvements had been made since the previous inspection in March 2016.
Our previous inspection in March 2016 found breaches of regulations relating to the safe, effective, caring, and responsive delivery of services. There were also concerns and regulatory breaches relating to the management and leadership of the practice, specifically in the well led domain. The overall rating of the practice in March 2016 was inadequate and the practice was placed into special measures for six months.
During the inspection in November 2016, we found evidence that improvements had been made. Our improved rating of good for the provision of well led services reflects the positive development of leadership and management systems to deliver significant progress in improving services across the board for all patient groups. Our rating of requires improvement for the provision of safe and effective services reflects that some positive changes have been made, however improvements are still required.
Our key findings across all the areas we inspected were as follows:
- Risks to patients were assessed and well managed. However, they had not ensured that blank prescription stationery was tracked within the practice. The practice implemented a change in process and sent an action plan following the inspection.
- There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
- The practice had responded to their vulnerable population group and had worked effectively to ensure that their needs were fully met. All staff within the practice showed that they recognised the signs when further support may be needed.
- Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
- 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. Improvements were made to the quality of care as a result of complaints and concerns.
- Patients said they did not find it easy to make an appointment; the practice had recognised and put measures in place to respond to this.
- 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.
- The provider was aware of and complied with the requirements of the duty of candour.
- The practice had recently integrated their Saturday flu clinics with a one-stop shop service to encourage patients to have regular health reviews.
The areas where the provider must make improvements are:
- Ensure blank prescription stationery distribution is monitored within the practice in accordance with current guidelines.
The areas where the provider should make improvements are:
- Ensure there is a system in place to action and mitigate the risks to patients if a vaccine cold chain breach occurs.
- Ensure patient outcomes are reviewed to ensure that patients with long term conditions receive appropriate care and treatment.
This service was placed in special measures in March 2016. Improvements have been made such that ratings of good for the delivery of responsive, caring and well led services and a rating of requires improvement for safe services have now been achieved. This has led to an improved rating of good. 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