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Inspection carried out on 31 Oct 2019

During a routine inspection

We carried out an announced comprehensive follow up inspection at Hungerford Surgery on 31 October 2019 as part of our inspection programme. We last inspected Hungerford Surgery on 25 September 2018 and we rated the practice Requires Improvement overall, with safe, effective and well-led rated as requires improvement. As a result of that inspection, two requirement notices were issued for breach of Regulation 17 (good governance) and Regulation 18 (staffing).

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.

Following this inspection, we have rated the practice as Good overall, but Requires Improvement for providing Effective services. Two out of six population groups have also been rated Requires Improvement.

We found that:

  • The practice had made improvements to its oversight of monitoring of staff training.
  • The practice now had a clear process in place for uncollected prescriptions and patients who had not collected prescriptions were followed up.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Staff feedback had improved and was positive and staff felt their concerns and suggestions were appropriately addressed.
  • Practice policies were fully embedded, and the practice had a process to ensure policies were appropriately reviewed.
  • The practice sought assurances that locum GPs had appropriate checks and training carried out prior to working at the practice.
  • Appropriate risk assessments had been carried out and acted upon in a timely manner.
  • The practice was taking appropriate steps to improve its uptake of cervical screening and childhood immunisations.
  • The practice had improved its security for blank prescriptions and was adequately logged and monitored. However, the practice policy did not reflect national guidance for security of blank prescriptions taken on home visits.
  • The practice was monitoring performance to improve outcomes for patients. However, there was limited monitoring of the outcomes in relation to exception reporting rates.

The practice was previously rated as Requires Improvement for the Effective domain. Although we saw significant improvement to the concerns raised around staff training at the last inspection, we continued rated the practice as Requires Improvement for providing effective services because:

  • The practice had high exception reporting in some areas which were higher than local and national averages and the practice monitoring of exception reporting had not identified these as areas to review.

Whilst we found no breaches of regulations, the provider should:

  • Review practice policy for prescription security in line with national guidance to minimise potential loss when attending home visits.
  • Review methods for monitoring exception reporting rates to improve practice performance to be in line with local and national averages.
  • Continue to take steps to improve cervical screening and childhood immunisation results.

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

Inspection carried out on 25/09/2018

During a routine inspection

This practice is rated as requires improvement overall. (Previous rating May 2016 - Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at Hungerford Surgery on 25 September 2018 as part of our inspection programme. We had initially intended to inspect this practice in January 2018 but that inspection was postponed due to a nationwide scheme in reducing the pressures on GP practices last winter.

At this inspection we found:

  • Significant staff changes had taken place, with a new senior GP in place who had also taken over the role of registered manager at the practice, the practice manager had been in post for six months.
  • Staff training was not completed in line with the practice’s own recommended schedule.
  • There was a lack of clarity on the roles and responsibilities of staff.
  • Policies were in place but there were shortfalls in their implementation to ensure consistency.
  • Recommendations from risk assessments were not consistently actioned in a timely manner or had not been undertaken at all. For example, there was no evidence of a comprehensive health and safety risk assessment having been completed at the practice.
  • Patient feedback was positive regarding the care and treatment they received at the practice, but it was negative in relation to patient experience when making an appointment.
  • The practice had adequate systems to manage risk so that 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.
  • There was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The areas where the provider should make improvements are:

  • Continue to review patient feedback regarding access to appointments and the experience of making an appointment.
  • Review how the practice can improve the uptake for cervical screening to achieve the national target of 80%.
  • Review how trends of complaints are identified and analysed to improve quality of care and service.
  • Review the accessibility of the practice’s complaints procedure for all patients.
  • Review how consent is gained and recorded by clinical staff.
  • Review how staff have been made aware of the new General Data Protection Regulations that came into effect in May 2018.

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

Inspection carried out on We have not revisited Hungerford 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

In June 2015 we found concerns related to staff receiving appropriate training and appraisals during a comprehensive inspection of Hungerford Surgery, Berkshire. Following the inspection the provider sent us an action plan detailing how they would implement systems to ensure every member of staff received appropriate role specific training and a yearly appraisal.

We carried out a desktop review of Hungerford Surgery on 26 April 2016 to ensure these changes had been implemented and that the service was meeting regulations. Our previous inspection in June 2015 had found a breach of regulations relating to Regulation 18, staffing. The ratings for the practice have been updated to reflect our findings

We found the practice had made improvements since our last inspection on 23 June 2015 and they were meeting the regulation relating to staffing that had previously been breached.

Specifically the practice was operating systems in relation to staff receiving appropriate training and appraisals. This included:

  • A consistent management process ensuring all staff received annual appraisals.

  • Formal arrangements were in place to ensure adequate levels of support and training relevant to their staff roles. For example, training in carrying out chaperone duties and in application of the Mental Capacity Act (2005).

We have changed 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. The practice was now meeting the regulation that had previously been breached.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 23 June 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hungerford Surgery on 23 June 2015. This was the first inspection of this practice.

The practice is adapting and changing having appointed new staff after a long period of stable staffing. Two new practice nurses joined in 2014 and the practice is awaiting the arrival of a new GP partner starting in July 2015. In addition plans are being made for the retirement of the senior partner and for the recruitment of a replacement.

Overall the practice is rated as good. The practice is rated as good for the delivery of safe, effective, caring and responsive services. The practice requires improvement for being well led. The practice is rated as good for delivery of care to the population groups of older people, people with long term conditions, families, children and young people, working age people, people whose circumstances may make them vulnerable and people experiencing poor mental health.

Our key findings were as follows:

  • The practice was responsive to patient demand for appointments. Feedback from patients was positive in this area and patients said they did not wait too long to be seen. Extended hours clinics were available every other Tuesday and on Saturday’s.
  • The practice was clean and tidy and the staff paid attention to reducing the risks of cross infection.
  • Patients who were carers and those living in care homes received high levels of care and support. Care plans were in place for patients in care homes and a flexible appointment system was in place for patients with caring responsibilities.
  • The practice prescribed medicines in line with best practice. Medicines and prescriptions were kept securely and managed appropriately.
  • Patient feedback from national surveys and patients we spoke with showed a high level of satisfaction with reception staff who were described as friendly and caring.
  • The GPs and management responded when they identified the practice could further improve services. For example an additional member of staff had been recruited to manage expansion of services and monitor the care of patients with long term conditions.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Operate consistent management processes to ensure all staff receive annual appraisals. Adequate levels of support and training relevant to their roles must also be delivered. For example, training in carrying out chaperone duties and in application of the Mental Capacity Act (2005).

In addition the provider should:

  • Further improve the care of patients with long term conditions by operation of robust recall systems ensuring as many patients in this group as possible receive their annual reviews and treatment monitoring.
  • Improve health promotion achievements by increasing the uptake of cervical screening, identifying the smoking status of more patients over the age of 16 and increase smoking cessation advice to those who smoke.
  • Ensure all health and safety risks are identified and appropriate risk assessments completed. For example, a risk assessment of substances hazardous to health.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice