Background to this inspection
Updated
5 May 2021
Redwood House Surgery is located in a converted detached house in Maidenhead, Berkshire and is part of East Berkshire Clinical Commissioning Group (CCG) and Windsor, Ascot and Maidenhead federation of GP practices. The practice has approximately 6,350 registered patients.
Services are provided from:
Redwood House Surgery,
Cannon Lane,
Maidenhead,
Berkshire,
SL6 3PH
The practice website is:
- www.redwoodhousesurgery.co.uk
The provider is a two-GP partnership who registered with the Care Quality Commission (CQC) in April 2018 and is registered to deliver the following Regulated Activities:
- Diagnostic and screening procedures
- Maternity and midwifery services
- Family planning
- Surgical procedures
- Treatment of disease, disorder or injury
In total, there are three GPs (two GP Partners and one salaried GP), two practice nurses and one health care assistant. The practice accesses a clinical pharmacist employed by the Primary Care Network (PCN) for medicine optimisation services. The practice manager is supported by team of administrative and reception staff and two medical secretaries.
According to data from the Office for National Statistics, the practice has patients from varying age groups with a slightly higher proportion of patients aged between 40 and 59. This part of Berkshire has high levels of affluence and low levels of deprivation. However, there are known pockets of high deprivation within the practice boundary. In general, people living in more deprived areas tend to have a greater need for health services. The practice catchment area has a high proportion of patients from a White British background, with approximately 12% of registered patients from Black and other minority ethnic groups.
How we carried out this inspection
We have not revisited Redwood House Surgery as part of this review because the practice was able to demonstrate they were meeting the regulations associated with the Health and Social Care Act 2008 without the need for an inspection.
We reviewed information provided by the practice, including evidence of the amendments to medicines management processes, prescribing audits, training records and further evidence which included an update on appointments and accessibility, cervical screening processes, cervical screening performance data and examples of anonymised patient feedback.
All were relevant to demonstrate the practice had addressed the breach of regulation identified at the inspection of March 2019.
Updated
5 May 2021
At our previous comprehensive inspection at Redwood House Surgery in Maidenhead, Berkshire on 20 March 2019 we found a breach of regulations relating to the provision of well-led services. The overall rating for the practice was ‘Good’, however we identified concerns relating to aspects of governance within the management of services. We therefore rated the well-led key question as ‘Requires Improvement’ and we issued a requirement notice in relation to the governance arrangements, specifically the arrangements to manage medicines and monitor staff training. The full comprehensive report on the March 2019 inspection can be found by selecting the ‘all reports’ link for Redwood House Surgery on our website at www.cqc.org.uk.
This inspection was a desk-based review carried out on 21 April 2021 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection in March 2019. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
At this inspection, on 21 April 2021, we found the practice had made improvements since our last inspection. Using information provided by the practice we found the practice was now meeting the regulation (Regulation 17: Good governance) that had previously been breached. We have amended the rating for this practice to reflect these changes, specifically Redwood House Surgery is now rated as good for the provision of well-led services whilst the overall rating of good remains.
At this inspection we found:
- A full medicines review had been completed and following this review, the practice had enabled a function within the clinical records system to restrict the number of repeat prescriptions issued to a patient before reauthorisation. This was implemented to safeguard the patient and ensure prescribing was within clinical guidelines and prescribing thresholds.
- The practice had introduced further enhancements to monitor patients who had been prescribed medicines designated as high risk. These enhancements included monthly searches, new clinical templates for consistency and to ensure guidelines were followed and clinical flags added to records for easy identification. We saw evidence of the enhanced high risk medicines monitoring following a review of submitted clinical audits for high risk medicines, including lithium (a type of medicine known as a mood stabiliser), methotrexate (a type of medicine called an immunosuppressant) and opiates (medicines prescribed for chronic pain).
- Training arrangements were consistent; there was a system to identify when staff had training and when it would need to be refreshed. We saw each module of training was identified in order of priority with a time frame for how long the module was valid for before the training would need to be to be repeated. There was evidence of performance monitoring and identification of personal and professional development. Furthermore, mandatory training requirements was also discussed as part of a strengthened recruitment process and training formed a key element of the induction programme for new member of staff.
- The practice had also addressed the areas we advised should be reviewed and improved, this included the recall process for cervical screening, monitoring prescription stationery and a review of patient feedback regarding accessibility and appointments.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care