Background to this inspection
Updated
27 July 2020
Easthampstead Surgery is a GP practice located in a converted residential dwelling in Bracknell, Berkshire. It is one of the practices within the Bracknell and Ascot federation of GP services and also a practice within East Berkshire Clinical Commissioning Group (CCG). In July 2019, the practice joined with six other local practices to form the Bracknell and District Primary Care Network. The practice provides general medical services to approximately 5,350 registered patients.
The practice is registered with the CQC to carry out the following regulated activities - Diagnostic and screening procedures, Treatment of disease, disorder or injury, Surgical procedures, Family planning and Maternity and midwifery services.
All services are provided from:
Easthampstead Surgery, 23 Rectory Lane, Easthampstead, Bracknell, Berkshire, RG12 7BB
The practice has two partners (one clinical, one non-clinical). The clinical team is led by the GP partner, who works full time and undertakes nine clinical sessions per week. There are three salaried GPs who provide six sessions per week and two long-term locum GPs who undertake six sessions per week on a regular basis. Another long-term locum offers ad hoc sessions when required. There is also an Advanced Nurse Practitioner (a nurse with additional skills and prescribing qualification) who undertakes two sessions per week.
The nursing team consists of two practice nurses, providing eight sessions per week and a health care assistant who undertakes three sessions per week.
The day-to-day operation of the practice is overseen by an assistant practice manager. The practice is also currently receiving practice management support from the local federation. A reception manager and five reception/administration staff support the practice manager in the daily running of the service.
The practice is open Monday to Friday from 8am until 6.30pm. The practice does not provide any extended hours. Extended hours are offered by the federation of GP practices on weekday evenings (6.30pm to 8pm) and Saturday and Sunday mornings by appointment. The practice has opted out of providing an out-of-hours service. Patients could access GP out of hours services via NHS 111.
During the COVID-19 pandemic, the practice have changed their appointments system to offer remote consultations via telephone and video calls. They also offer patients online services through their website, including online consulting.
The patient profile for the practice has an above-average working age population and children under 18, and fewer than average older patients, aged over-65. The locality has a medium to low deprivation level, although there are areas of high deprivation within the practice boundary. 11% of the practice area population are from a black or minority ethnic background.
The practice has been inspected before in April 2016, January 2017, July 2017 and March 2019. The full reports for the practice can be found by searching Easthampstead Surgery and using the “all reports” tab on our website .
Updated
27 July 2020
We previously carried out an announced comprehensive inspection at Easthampstead Surgery on 6 March 2019 as part of our inspection programme. We rated the practice as Good overall, however we found a breach of regulations and rated Well led as Requires Improvement. You can read the full report by selecting the ‘all reports’ link for Easthampstead Surgery on our website at .
We were mindful of the impact of the Covid-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what type of inspection was necessary and proportionate, this was therefore a desk-based inspection. On 10 July 2020, we carried out the desk-based review to confirm that the practice had carried out its plan to meet the legal requirements in relation to the breach of regulations that we identified at our previous inspection in March 2019.
We found that the practice is now meeting those requirements and we have amended the rating for this practice accordingly. The practice is now rated Good for the provision of Well led services. We previously rated the practice as Good for providing Safe, Effective, Caring and Responsive services.
We based our judgement of the quality of care at this service on a combination of:
- what we found when we reviewed the information sent to us by the provider
- information from our ongoing monitoring of data about services and
- information from the provider.
We have rated Well led as Good because:
- The practice had established a new medication review policy and recall process and improved the number of patients receiving an annual medication review.
- Recruitment processes had been audited and updated to ensure all appropriate documentation was held within staff files. Staff had been offered a health status questionnaire to identify if reasonable adjustments were required.
- Monitoring of staff training needs was effective and staff were offered training appropriate to their role, including safeguarding.
- Annual fire drills had been carried out and scheduled in for the following year.
The practice had also made improvements since the last inspection in the areas of:
- Recall and uptake of patients eligible to receive a cervical screening test had been reviewed. Prior to the COVID-19 outbreak, the practice was actively undertaking searches and recalling patients for their cervical screening test. They also offered the services of the federation for extended hours (evenings and weekends) for patients who could not attend during core hours. The COVID-19 pandemic had impacted on many services, including offering routine cervical screening tests. We saw official figures from Public Health England which showed the practice had achieved 75% uptake in cervical screening in December 2019, compared to 73.5% in March 2019. This was still below the 80% national target and the practice told us they were planning to reimplement the active recall programme once the COVID-19 pandemic eases.
- The practice had reviewed how they captured all feedback including verbal complaints and compliments received by the reception team. All the feedback was shared at staff meetings and utilised to understand any themes and trends.
The areas where the provider should make improvements are:
- Continue to engage with patients and improve the uptake for cervical screening to achieve the national target of 80%.
- Continue to improve the numbers of medication reviews to ensure all patients receive an annual review.
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