All inspections: Redwood House Surgery - Care Quality Commission

We carried out a review of the data available to us about Redwood House Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Redwood House Surgery, you can give feedback on this service.

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

We carried out an announced comprehensive inspection at Redwood House Surgery on 20 March 2019 as part of our inspection programme. The practice registered with the CQC in April 2018 and this was their first comprehensive inspection.

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 for all population groups.

We rated the practice as good for safe, effective, caring and responsive services because:

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.

We rated the practice as requires improvement for providing well-led services because:

Governance arrangements were not effective for monitoring patients on high risk medicines and repeat medicines.
Staff training had been inconsistently reviewed to ensure all staff had received essential training such as fire safety, health and safety, infection control and mental capacity act.

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 the recall process for women eligible for cervical screening to ensure uptake.
Review the January 2019 intercollegiate guidance for children’s safeguarding and offer additional training to staff to attain the appropriate level, where neccessary.
Review the process for monitoring and reporting uncollected prescriptions.
Consider how improvements could be made following patient feedback about accessibility and appointments.

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

Redwood House Surgery

All Inspections

6 July 2023

During a monthly review of our data

We did not visit the practice as part of this review because the practice was able to demonstrate that they were meeting the regulations associated with the Health and Social Care Act 2008 without the need for a visit.

During an inspection looking at part of the service

20 March 2019

During a routine inspection