The Care Quality Commission
  • Doctor
  • GP practice

Threeways

Overall: Good read more about inspection ratings

Pennylets Green, Stoke Poges, Slough, Berkshire, SL2 4AZ (01753) 643445

Provided and run by:
Threeways

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Threeways 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 Threeways, you can give feedback on this service.

11 December 2019

During an annual regulatory review

We reviewed the information available to us about Threeways on 11 December 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

22/06/2018

During a routine inspection

This practice is rated as Good overall.

The previous inspection was in August 2016 and the practice was rated Good.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive at Threeways in Stoke Poges, Buckinghamshire on 22 June 2018. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.

  • Staff involved and treated patients with compassion, kindness, dignity and respect.

  • The practice had increased activity to proactively identify and support people with caring responsibilities. This included work with Carers Bucks (an independent charity to support unpaid, family carers in Buckinghamshire) to increase identification of carers who were registered at the practice.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

  • There was a focus on continuous learning and improvement at all levels of the organisation. The practice was fully aware of the developments within South Buckinghamshire and the local health economy.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We have not revisited Threeways Surgery 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

Letter from the Chief Inspector of General Practice

At our previous comprehensive inspection at Threeways in Stoke Poges, Buckinghamshire on 2 August 2016 we found a breach of regulations relating to the safe delivery of services. The overall rating for the practice was good. Specifically, we found the practice to require improvement for the provision of safe services, whilst the practice was rated good for providing effective, caring, responsive and well-led services. The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for Threeways on our website at www.cqc.org.uk.

This inspection was a desk based review carried out on 12 April 2017 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 on 2 August 2016. This report covers our findings in relation to those requirements and improvements made since our last inspection.

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 that had previously been breached. We have amended the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective, caring, responsive and well led services. Overall the practice is now rated as good. All six population groups continue to be rated as good.

Our key findings were as follows:

  • The practice had established and was now operating safe systems to assess, manage and mitigate potential risks relating to medicines within the cold chain.
  • National guidance had been embedded into the practice regarding patient specific directions (instructions to administer a medicine to a named patient).
  • The practice had implemented a failsafe system and was now effectively managed and monitored all cervical screening results the practice received.
  • The programme of two cycle clinical audit had increased. We saw a variety of completed clinical audits which effectively monitored and improved patient outcomes.
  • The practice had taken steps to ensure recruitment procedures were operated effectively which ensured that employees met the requirements for the role. This included a comprehensive assurance system and checklist for temporary members of staff which ensured the practice had all required evidence of all relevant up to date registrations and competencies for safe working.
  • The practice had review existing arrangements and all clinical staff had suitable and appropriate indemnity insurance. Indemnity insurance is used for professional negligence claims, or allegations of malpractice, received against a member of staff in the course of their professional duties.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

2 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Threeways on 2 August 2016.

Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were not assessed and well managed. The practice had not ensured that there was a failsafe system to monitor all cervical screening results were received back in the practice.
  • The vaccine storage policy was not followed and no mitigating action was taken when there was a breach in the cold chain.
  • 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 found it easy to make an appointment.
  • 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 areas where the provider must make improvements are:

  • The provider should assess the risk to the health and safety of patients when receiving care and treatment. Including the safe management of medicines within the cold chain.
  • Ensure that patient specific directives (PSD) are used in accordance with national guidelines.
  • Ensure that there is a failsafe system to monitor all cervical screening results are received back in the practice.
  • Ensure that there is evidence of a programme of clinical audit to drive improvement to patient outcomes.

There were also areas of practice where the provider should make improvements:

  • Ensure recruitment procedures are operated effectively to ensure that employees meet the requirements for the role. For example checks on locum GPs.
  • Ensure all clinical staff have adequate indemnity insurance.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice