The Care Quality Commission
  • Doctor
  • Out of hours GP service

Archived: King Edward VII Hospital Primary Care Centre

Overall: Good read more about inspection ratings

King Edward VII Hospital, St Leonards Road, Windsor, Berkshire, SL4 3DP (01344) 392674

Provided and run by:
East Berkshire Primary Care Out Of Hours Services Limited

Important: This service was previously registered at a different address - see old profile

All Inspections

5 July 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

Our previous comprehensive inspection at East Berkshire Primary Care Out of Hours Services Limited – King Edward VII Hospital Primary Care Centre on 5 October 2016 found a breach of regulations relating to the safe and well-led delivery of services. The overall rating for the service was requires improvement. Specifically, we found the service to require improvement for the provision of safe and well led services. The service was rated good for providing effective, caring and responsive services. The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for East Berkshire Primary Care Out of Hours Services Limited on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 5 July 2017 to confirm that the service 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 October 2016. This report covers our findings in relation to those requirements and improvements made since our last inspection.

We found the service had made improvements since our last inspection. At our inspection on the 5 July 2017 we found the service was meeting the regulations that had previously been breached. We have amended the rating for the service to reflect these changes and improvements. East Berkshire Primary Care Out of Hours Services Limited – King Edward VII Hospital Primary Care Centre is now rated good for the provision of safe, effective, caring, responsive and well led services. Overall the service is now rated as good.

Our key findings were as follows:

  • East Berkshire Primary Care Out of Hours Services had comprehensively reviewed the existing governance framework in place and embedded the current models of best practice across all of the services locations.
  • The medicines management team had implemented new processes to ensure that the service actioned all patient safety alerts and MHRA (Medicines and Healthcare Products Regulatory Agency) alerts.
  • The service reviewed the Controlled Drug Home Office licence requirements and contacted the Home Office for confirmation and to begin the registration process.
  • Prescription stationary was stored securely and tracked through the service at all times; this included when prescriptions were in the out of hours vehicles.
  • There was now a designated person specifically to manage quality, ensure improvements were made and sustained. This included consideration of location specific clinical audits to review, monitor and improve outcomes for people accessing care and treatment at the different locations within the service. Furthermore, this included a review of all the feedback and areas of improvement that we reported on following the October 2016 inspections. For example, vehicle equipment checks were completed in line with the service policy and regular infection control checks completed on-site.
  • Information about translation services and other services available was displayed in the reception area informing patients these services were available. All staff had received awareness training to increase awareness of translation services and how to request a translator.
  • Arrangements to manage training had been strengthened. Specifically, we saw all staff undertaking chaperoning duties, including the drivers of out of hours vehicles, had received appropriate chaperone training. Furthermore, as part of the review of training arrangements a member of staff had been appointed to monitor all training arrangements within the service.
  • There was an appraisal programme and all staff had received an annual appraisal within the last 12 months.
  • Information for patients about the complaints procedure was clearly on display and carried in vehicles for patients receiving care and treatment in their place of residence.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

5 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at East Berkshire Primary Care Out of Hours Services Limited – King Edward VII Hospital Primary Care Centre on 5 October 2016. Overall the service is rated as requires improvement.

Specifically, we found the service to require improvement for the provision of safe and well led services. The service is rated good for providing effective, caring and responsive services.

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

  • There was an effective system for reporting and recording significant events. A wide range of events was reported. They were systematically assessed and dealt with.
  • Risks to patients were assessed and well managed. However, some systems to address these risks were not implemented well enough to ensure patients were kept safe. For example, the service had not always taken action appropriate action in relation to recent alerts from the Medicines and Healthcare Products Regulatory Agency (MHRA).
  • Infection control monitoring checks were not recorded and needle stick injury and sharps protocols were not available or displayed in the clinical areas. Blank prescription forms for use in printers were not tracked appropriately and the monitoring log was not maintained.
  • There were limited clinical audits or monitoring of quality improvement for extended hours service.
  • 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. However, five out of seven nurses working in the extended hours service had not received an appraisal within the last 12 months.
  • There were safeguarding systems in place for both children and adults at risk of harm or abuse as well as palliative care (care for the terminally ill and their families) patients who accessed the out of hours to the service.
  • Verbal and written patient feedback said they were treated with compassion, dignity and respect and despite the service provided single episodes of care patients were involved in their care and decisions about their treatment. Comment cards that patients completed confirmed this finding.
  • Patients said they found it easy to make an appointment and data showed most patients were seen or contacted in a timely manner. The premises were well equipped to treat patients and meet their needs.
  • The provider’s specific written complaints information was not available or displayed in the King Edward VII Hospital Primary Care Centre about how to complain. The complaints we reviewed were fully investigated by a senior member of staff and patients were responded to with an apology and full explanation.
  • There was a clear leadership structure. Staff felt supported by East Berkshire Primary Care Out of Hours Services Limited management. However, the leadership and management of the extended hours service and relationship with the local clinical commissioning group programme board required improvement to ensure a safe and well led service.
  • The service was aware of and complied with the requirements of the duty of candour.

However, there were also areas of practice where the service needs to make improvements. The areas where the service must make improvements are:

  • Ensure the governance framework and processes are improved for all services. Including a review of the systems and processes to ensure that the service actions all patient safety alerts and MHRA (Medicines and Healthcare Products Regulatory Agency) alerts.
  • Review and improve the system in place to ensure management of blank prescription forms for use in printers.
  • Ensure relevant infection control information is available and monitoring records maintained of the infection control checks carried out at the premises.
  • Develop and implement clinical quality measures and monitoring in order to drive and ensure continuous improvement for the extended hours service.

The areas where the service should make improvements are:

  • Ensure information about translation services are displayed in the reception area informing patients this service is available. Ensure all staff are aware about the translation service.
  • Ensure that staff undertaking chaperoning duties have received the appropriate training.
  • Ensure all staff had received an annual appraisal within the last 12 months.
  • Information to patients about the complaints procedure should be available and clearly displayed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice