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Reports


Review carried out on 9 September 2021

During a monthly review of our data

We carried out a review of the data available to us about Binfield Road Surgery on 9 September 2021. 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 Binfield Road Surgery, you can give feedback on this service.

Review carried out on 31 January 2020

During an annual regulatory review

We reviewed the information available to us about Binfield Road Surgery on 31 January 2020. 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.

Inspection carried out on 23 October 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice


We carried out an announced comprehensive inspection at Binfield Road Surgery on 7 March 2017. The practice was rated good overall and requires improvement for providing services that were safe. The full comprehensive report from the March 2017 inspection can be found by selecting the ‘all reports’ link for Binfield Road Surgery Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced desk-based review carried out on 23 October 2017 to confirm that the practice had carried out their plan to meet the recommendations we made in our previous inspection on 7 March 2017. This report covers our findings in relation to those recommendations made at our last inspection.

At our previous inspection undertaken on 7 March 2017, we rated the practice as requires improvement for providing safe services as:

  • Two members of staff were acting as chaperones without having had a DBS check undertaken prior to employment.

  • The fire risk assessment did not provide a comprehensive assessment of fire risks in the practice.

In addition to the breaches of regulation we identified we also suggested areas where the provider should make improvements including:

  • Take steps to make the practice complaints procedure easily accessible to patients and provide formal written response to written complaints.

  • Review systems for the storage and monitoring of Patient Group Directions (PGD).

  • Continue to work on embedding learning from significant events.

  • Continue to work on improving patient satisfaction regarding waiting times.

  • Consider recording multidisciplinary team and clinical meetings in a separate document in addition to within individual patient records.

The practice is now rated as good for the key question: Are services safe?

Our key findings were as follows:

  • All staff had received a DBS check and a practice policy had been drafted which required all staff who undertook the chaperoning role to have a DBS check. In addition their recruitment policy had been updated to refer to the new DBS policy.

  • The practice had updated their internal fire risk assessment using Health and Safety Executive guidelines.

In addition:

  • The practice provided us with a complaint log of recent complaints although this did not indicate that formal written responses were sent to patients when they complained in writing. The practice provided a copy of the complaint poster used to advertise the complaints policy.

  • The practice provided copy of their PGD policy which placed the responsibility for ensuring PGDs were valid on the individual practitioner with signed copies of these being kept by the practice.

  • The practice provided an example of a recent significant event which demonstrated learning and action taken.

  • The practice continued to minute multidisciplinary discussions in patient records and kept a log of the patients discussed in each meeting in an effort to reduce the administrative burden on clinical staff.

No further action had been taken to assess whether there had been any improve patient satisfaction with appointment waiting times. The period where data had been collected for the most recent national GP patient survey results pre dated the action the practice had taken to improve satisfaction with waiting times.

Areas where the practice should make improvement:

  • Continue with action to assess the impact of this on patient satisfaction.

  • Consider employing someone with suitable expertise in fire safety to undertake a fire risk assessment.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 7 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Binfield Road Surgery on 19 April 2016. The overall rating for the practice was requires improvement. The full comprehensive report from the inspection undertaken on 19 April 2016 can be found by selecting the ‘all reports’ link for Binfield Road Surgery on our website at www.cqc.org.uk.

As a result of our findings from this inspection CQC issued a requirement notice for the identified breaches of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Specifically we found concerns related to the management of medicines, recruitment, processes to manage and mitigate risk, staff training and procedures to enable the practice to respond to significant events.

This inspection was undertaken over six months from the last inspection as the practice was rated as inadequate for one of the key questions; are services safe? This was an announced comprehensive inspection completed on 7 March 2017. Overall the practice is now rated as good.

Our key findings were as follows:

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events. Events were discussed at practice meetings but discussions with some staff indicated that learning was not embedded.
  • Though the practice had systems to assess and address risks to patient safety, the practice fire risk assessment did not adequately mitigate against potential fire risks or adhere to the format outlined in their fire safety risk assessment. The practice had not completed criminal background checks for all staff in accordance with their recruitment policy.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about how to complain was available only upon request from staff. However, we saw improvements were made to the quality of care as a result of complaints and concerns.
  • Health promotion leaflets and information on local services was available.
  • Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. Patient survey feedback suggested that patients would have to wait a long time to be seen when they arrived for their appointment though the practice had taken action in response to this feedback.
  • 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 the requirements of the duty of candour.

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

Importantly, the provider must:

  • Ensure that risks relating to the health, safety and welfare of service users including those related to fire and staff recruitment are assessed and mitigated.

In addition the provider should:

  • Take steps to make the practice complaints procedure easily accessible to patients and provide formal written response to written complaints.

  • Review systems for the storage and monitoring of Patient Group Directions.

  • Continue to work on embedding learning from significant events

  • Continue to work on improving patient satisfaction regarding waiting times.

  • Consider recording multidisciplinary team and clinical meetings in a separate document in addition to within individual patient records.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 19 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Binfield Road Surgery on 19 April 2016. Overall the practice is rated as requires improvement.

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

  • Staff did not understand what constituted a significant event and there were inconsistent accounts among the staff we spoke to of how significant events were reported and managed. No one in the practice was able to supply a significant event policy on the day of the inspection. Of the two significant events the practice had identified within the last twelve months, reviews and investigations were thorough. Although staff were able to demonstrate learning from these events this was not documented so that the practice could undertake a subsequent review of the effectiveness of any actions put in place.
  • Risks to patients were either not assessed or not well managed particularly in respect of fire safety, equipment, medicines management, consent and infection control.
  • Data showed patient outcomes were comparable to those in the locality and nationally. Consent for minor surgery was not always recorded using the practice’s consent forms.
  • The majority of patients said they were treated with compassion, dignity and respect and felt cared for supported and listened to.
  • Information about local services in the practice waiting areas was limited though the practice had translated some information into different languages spoken by its patient population. In addition the practice informed us that they were able to print off health promotion materials and information from their computer system and that they had a large number of leaflets available in different languages.

  • Urgent appointments were available on the day they were requested.

  • The practice had a number of policies and procedures to govern activity, but some were not sufficiently detailed to ensure that patients were kept safe; including safeguarding, chaperoning and health and safety.
  • The practice had proactively sought feedback from patients and had an active patient participation group.

The areas where the provider must make improvements are:

  • Ensure that all staff have received required mandatory training in accordance with guidance.

  • Put in place effective governance arrangements and policies and procedures which ensure staff and patient safety and mitigate risk.

  • Review the practice’s significant event process and ensure that staff are familiar with the policy and adequately able to identify things which may constitute a significant event.

  • Ensure that staff within the practice are chaperoning in accordance with best practice.

  • Assess and address infection risks in areas where invasive procedures are carried out.

  • Ensure that there are appropriate systems in place for recording consent.

  • Ensure that medicines and prescriptions are always securely stored.

  • Ensure that systems are in place to monitor the expiry dates of clinical equipment.

  • Improve the processes in place for monitoring vaccine fridge temperatures and keep a record of the reason and actions taken for any out of range readings.

  • Ensure that systems are in place to monitor the professional registrations of clinical staff.

  • Ensure that systems are in place to monitor staff immunity to common communicable diseases.

  • Ensure health and safety policies and procedures sufficiently mitigate against the risk of fire.

  • Have systems and process in place to ensure that all electrical equipment is safe to use.

In addition the provider should:

  • Improve the identification of and support for those with caring responsibilities among the practice’s population and provide information for carers in the reception area.

  • Ensure that staff are appraised annually.

  • Consider undertaking regular documented strategic business reviews.

  • Ensure records are kept and shared of action points and learning from meetings.

  • Ensure the complaints policy and responses comply with requirements of The Local Authority Social Services and NHS Complaints (England) Regulations 2009.

Where a practice is rated as inadequate for one of the five key questions or one of the six population groups the practice will be re-inspected within six months after the report is published. If, after re-inspection, the practice has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place the practice into special measures. Being placed into special measures represents a decision by CQC that a practice has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice