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Melrose Surgery, Reading Good Also known as Melrose Surgery

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating


Updated 17 May 2018

This practice is rated as good overall. This was the first inspection at this practice.

The key questions 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 inspection at Melrose Surgery on 9 April 2018 as part of our planned inspection programme.

At this inspection we found:

• When incidents happened, the practice learned from them and improved their processes.

• Safety systems were operated effectively; including health and safety and emergency risk management.

• Staff had the skills, knowledge and experience to carry out their roles.

• Performance data, particularly for people with long-term conditions were better than local and national averages.

• There were systems to review the effectiveness of the care and evidence that the practice was auditing medicines and antimicrobial use.

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

• Patients found the appointment system easy to use and reported that they were able to access care when they needed it. The practice offered a flexible range of appointments and services.

• There were proactive governance processes and systems for business planning, risk management, performance and quality improvement.

• Patient feedback was acted on where improvements were identified.

We saw one element of outstanding practice:

  • Diabetic patients received annual Doppler ultrasound assessments within the practice by staff trained to do so. A Doppler ultrasound assessment provides clinicians with imaging of foot arteries and this assessment means patients can be informed of any potential complications regarding their foot health earlier than they may otherwise be.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection areas



Updated 17 May 2018

We rated the practice as good for providing safe services.

Safety systems and processes

The practice had systems to keep people safe and safeguarded from abuse.

  • The practice had systems to safeguard children and vulnerable adults from abuse. Staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Reports and learning from safeguarding incidents were available to relevant staff.
  • All child safeguarding requests by safeguarding teams were replied to and all alerts raised by the child safeguarding were followed up by a request for an appointment with the GP safeguarding lead.
  • Staff who acted as chaperones were trained for their role and all of them had received a DBS check. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.)
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • There was an effective system to manage infection prevention and control.
  • The arrangements to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

There were adequate systems to assess, monitor and manage risks to patient safety.

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
  • The practice was equipped to deal with medical emergencies and staff were trained in emergency procedures.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians had guidance on how to identify and manage patients with severe infections including sepsis
  • When there were changes to services, such as building work or staffing the practice assessed and monitored the impact on safety.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • The care records we saw showed that information needed to deliver safe care and treatment was available to staff. There was a documented approach to managing test results.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made timely referrals in line with protocols. However, there was no formal follow up system in place to check patients had received an appointment within two weeks of an urgent referral. The practice implemented a formal system on the day of inspection to ensure any patients requiring urgent referrals were seen in good time by a specialist service.

Appropriate and safe use of medicines

The practice had reliable systems for appropriate and safe handling of medicines.

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with current national guidance.
  • There were effective systems for checking patients were safe to continue taking their long term medications including initial reviews three months after starting a new medication and ongoing annual checks.
  • The prescribing of high risk medicines was monitored and patients taking these medicines were supported and reviewed in order to ensure they had the necessary blood tests or other tests required.
  • The practice had low antibiotic prescribing compared with other practices locally. It had implemented antimicrobial stewardship processes in line with local and national guidance.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately.

Track record on safety

The practice had a positive track record on safety.

There were risk assessments in place:

  • A comprehensive fire risk assessment was in place and actions required to improve safety had been undertaken.
  • A legionella (a bacterium which lives in water systems) risk assessment had been undertaken and annual testing of the water system was in place.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and took action to improve safety in the practice.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts.

Please refer to the Evidence Tables for further information.








Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable