The Care Quality Commission
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  • Out of hours GP service

Archived: St Marks Hospital Primary Care Centre

Overall: Good read more about inspection ratings

St Marks Hospital Outpatients Department, St Marks Road, Maidenhead, Berkshire, SL6 6DU (0118) 936 5390

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

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 – St Marks 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 – St Marks 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.
  • 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.
  • The service had reviewed the internal arrangements to respond to emergencies and major incidents. This review had led to the emergency grab bags positioned throughout the service with appropriately signage and awareness training for staff.
  • There was a monitoring system to manage risks associated with cleanliness, infection control and consumables (medical equipment and medicines) across the service. Internal auditing (including premises and out of hours vehicles) infection control auditing and quality auditing was now bi-monthly and specific to each site. We saw there had been a complete review of the medical equipment and medicines held across the service.
  • The service had reviewed and taken steps to improve signage across all five primary care centres to ensure patients visiting each site could access the services without delay.
  • 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.
  • 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.
  • There was an appraisal programme and all staff had received an annual appraisal within the last 12 months.

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 St Marks 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 were two interlinked services from St Marks Hospital Primary Care Centre. One service was the Out of Hours (OOH) GP service and the other an extended hours service, which offered pre-bookable appointments with GPs and practice nurses.
  • There was an effective system for reporting and recording significant events. A wide range of events were 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, staff who acted as chaperone had not received appropriate training to reflect the role and purpose and the service had not responded to recent alerts from t. The systems to monitor the safe use of equipment had not identified out of date medical supplies on the extended hour’s consultation room trolleys and the storage of emergency medicines could present a delay in care and treatment.
  • There were limited clinical audits or monitoring of quality improvement.
  • 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, members of staff working in one of the two services 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 OOH to the service.
  • Verbal and written patient feedback said they were treated with compassion, dignity and respect. Patients were involved in their care and decisions about their treatment. CQC comment cards that patients completed confirmed this finding.
  • There was limited information on display about how to complain and no complaint information was available in the mobile vehicles for patients receiving care and treatment in their place of residence. The complaints we reviewed were fully investigated by a senior member of staff and patients were responded to with an apology and full explanation.
  • Patients said they found it easy to make an appointment and data showed most patients were seen or contacted in a timely manner. The service was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure. Staff felt supported by 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 quality and well led service.
  • The service was aware of and complied with the requirements of the duty of candour.
  • The provider had a clear vision and strategy promoting positive outcomes for patients in Berkshire and Richmond.
  • The provider has been working with the local Clinical Commissioning Groups to discuss how to improve and maintain response times for patients accessing the out of hour’s service.

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 East Berkshire Primary Care Out of Hours Services Limited services and processes to ensure that the service actions all patient safety alerts and MHRA (Medicines and Healthcare Products Regulatory Agency) alerts. This would include a review of the governance arrangements and operating procedures for the services use of Controlled Drugs including an application for a Controlled Drugs Home Office license. Undertaking site specific quality improvement activity.
  • Review the storage and availability of emergency medicines to ensure they are available quickly in the event of an emergency.
  • Implement recording systems for the medical supplies and equipment used in the extended hours service.

The areas where the service should make improvements are:

  • Review signage ensuring patients visiting the OOH service can access the service without delay.
  • Ensure that staff undertaking chaperoning duties have received the appropriate training, including the drivers of the OOH vehicles by 31 October 2016.
  • Information to patients about the complaints procedure should be on display and carried in vehicles to be made available to patients receiving care and treatment in their place of residence.
  • Ensure all extended hours nurses had received an annual appraisal within the last 12 months.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

18, 22 April 2013

During a routine inspection

East Berkshire Primary Care Out of Hours Services (EBPCOOH) provides out of hours GP services to the Slough, Windsor & Maidenhead, South Buckinghamshire, and Bracknell areas. It provides these services at St. Marks Hospital, the Herschel Medical Centre,and Heatherwood Hospital. During the day only, EBPCOOH also runs an urgent care centre at St. Marks Hospital which is led by a team of nurses. This inspection relates to visits to the urgent care centre and out of hours service at St. Marks Hospital.

During our inspection, we found that the EBPCOOH web site provided clear explanations of the services offered and how they could be accessed. There was a service guide, information about how to make a complaint or provide feedback, and general health information. At the reception desk at St. Marks Hospital, there were also leaflets explaining the services offered by the urgent care centre.

We spoke with two people who used services at the urgent care centre and three people and their relatives who used the out of hours service. All the people we spoke with told us they were very pleased with the service. People said they were seen and treated promptly and felt nurses and doctors were very approachable. Those people who used the urgent care centre commented particularly on the professionalism of the nurses and rated this highly. One person told us the treatment "was excellent, first class."

We found that people using the service were provided with appropriate care to meet their needs. National clinical guidelines and recommendations were understood and implemented. Infection prevention and control measures were in place. Equipment was regularly maintained and there were well established protocols for reporting faulty equipment. There were systems in place for monitoring the quality and safety of services provided to people.