- GP practice
Emmer Green Surgery
All Inspections
21/11/2019
During a routine inspection
We decided to undertake an inspection of this service on 21 November 2019 following our annual review of the information available to us which took place in April 2019. This inspection looked at the following key questions; was the service providing effective and well led services for the registered patient population. We decided not to inspect whether the practice was providing safe, caring or responsive services as there was no information from the annual regulatory review which indicated this was necessary.
The practice remains rated Good overall.
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 good for all population groups.
We found that:
- 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 were developed and supported to ensure services were of high quality.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- The practice had planned services to meet the demands of a rapidly increased practice population and had managed the increase of 3,000 patients effectively.
- The practice was aware of patient feedback in regards to access to services and took action to maintain appropriate access.
- Services were tailored to meet patients’ needs.
- Governance systems were operated including quality improvement initiatives.
- The practice was engaged in local initiatives and worked effectively alongside partners in the local healthcare system.
Whilst we found no breaches of regulation the provider should:
- Continue to review outcomes for patients diagnosed with long term conditions.
- Evaluate the change in consent procedures to confirm the new system is operated effectively.
- Review the new process reminder process for cervical cytology testing with a view to increasing uptake.
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
We have not revisited Emmer Green Surgery as part of this review because they were able to demonstrate that they were meeting the standards without the need for a visit
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out a comprehensive inspection on 19 November 2014 and published a report setting out our judgements. We found improvements were required regarding provision of safe services. In July 2015 we carried out a focussed desktop review (an inspection where we did not need to visit the practice) to ensure that since our last inspection, in November 2014, systems had been put in place to manage medicines safely. We also received evidence from the provider showing the practice had expanded and improved training for staff on how to reduce the risks of cross infection and in chaperone duties. We found the improvements had been made and the practice was providing safe services.
Our findings from this review were:
- Evidence sent to us showed medicines were kept securely and vaccines administered in accordance with legislation.
- The practice had also taken action on matters relating to cleanliness and infection control, safeguarding and recruitment which improved the way they managed these aspects of their service
We have changed the rating for this practice in respect of the safe domain to reflect these improvements. The practice is now rated good for the provision of safe, effective, caring, responsive and well led services.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
19 November 2014
During a routine inspection
Letter from the Chief Inspector of General Practice
Emmer Green surgery is based in a purpose built practice that has been extended over the years as the number of patients increased. Over 9,000 patients are registered with the practice. We carried out an announced comprehensive inspection of the practice on 19 November 2014. This was the first inspection of the practice since registration with the CQC.
The feedback received from patients was positive. Patients spoke positively about the care they received and described the staff as caring. The practice results for the national GP patient survey 2013 mostly compared well with the clinical commissioning group (CCG) and national averages. The practice was aware the satisfaction rating for obtaining appointments was not as high as other practices in the area. Changes had been made to the appointment system and an additional clinic had been established in the last month.
We spoke with ten patients during the inspection. We met with two members of the patient participation group and spoke with six GPs and a range of practice staff.
Emmer Green Surgery was rated good overall.
Our key findings were as follows:
- the practice operates mostly safe systems. However, improvements must be made in the way medicines are managed.
- GPs treat patients in accordance with national and local guidelines. Staff are trained and knowledgeable. The practice works with other services to ensure patients with complex needs are cared for appropriately. We saw evidence of close working relationships with consultants in both psychiatry and diabetology that benefitted patient care.
- patients told us and we observed that they were treated with care and compassion.
- the practice offers a range of appointment options and alternative means of booking appointments, including online booking.
- the practice is well led. Staff show a strong commitment to delivering patient centred care in a timely manner and are involved in planning services for the future.
We saw areas of outstanding practice including:
- patients with long term mental health problems who moved to other locations within Reading were able to remain registered at Emmer Green Surgery to support continuity in their care and treatment.
- an ear nose and throat (ENT) clinic was held at the practice by one of the GPs qualified in this specialty. Working with local commissioners enabled the practice to provide physiotherapy, talking therapies and speech and language clinics on site. This benefitted patients who found it easier to attend the practice rather than local hospital or clinics elsewhere.
There were areas of practice where the provider needs to make improvements.
Importantly, the provider must:
- introduce a system to confirm that actions required from national medicine alerts have been taken.
- ensure fridges holding vaccines and medicines required to be stored at a controlled temperature are locked when not in use.
- cease the practice of the health care assistant administering flu immunisations without prior written authorisation from an approved prescriber.
In addition the provider should:
- ensure practice nurses are familiar with the fridge failure protocol contained in the service continuity plan.
- improve the training of reception staff who occasionally carry out chaperone duties to ensure they are fully trained in this role
- provide updating training on infection control for the infection control lead and provide training in infection control to all staff appropriate to their role.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice