We carried out an announced comprehensive inspection at Theale Medical Centre in Berkshire on 27 February 2019 and 5 March 2019. The overall rating for the practice was Requires Improvement. Given the concerns we found, we issued a Warning Notice for Regulation 17 (Good Governance).
We carried out an announced focussed follow-up inspection on 16 July 2019 to confirm that the practice had met the legal requirements in relation to the breach of regulation that we identified in our previous inspection in February and March 2019. This was an unrated inspection, however we found that the practice had made significant improvement and had met the requirements of the Regulation 17 (Good governance) Warning Notice.
The full history of reports and inspection findings including the comprehensive report from February 2019, March 2019 and the unrated focussed inspection in July 2019 can be found by selecting the ‘all reports’ link for Theale Medical Centre on our website at www.cqc.org.uk.
Why we carried out this inspection
We carried out an announced comprehensive inspection on 24 November 2021. This inspection was undertaken to ensure improvements had continued to be made and sustained since our previous inspections and to provide a new rating.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
- Conducting staff interviews using video conferencing
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A short site visit including observations of the dispensary
- Discussions with practice staff, local care homes who access GP services from the practice and the patient participation group.
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.
This practice is now rated as GOOD overall.
The key questions at this inspection are rated as:
- Are services safe? – Good
- Are services effective? – Good
- Are services well-led? – Good
We found that:
- It was evident the practice had gone through a period of transition since our previous inspections in 2019 and the COVID-19 pandemic. Significant improvements had been made and systems implemented to manage and monitor risks. Staff we spoke with recognised the endeavours of the new leadership team and were keen to be part of the new developments.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm, including associated risks to the COVID-19 pandemic.
- The practice was able to demonstrate staff had the skills, knowledge and experience to carry out their roles. Staff members were appraised annually and received appropriate supervision and training.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
- Continuous monitoring of practice procedures, clinical outcomes and clinical registers was in place to ensure improvements were maintained. This included child immunisations and cervical screening uptake.
- The way the practice was led and managed promoted the delivery of high-quality, person-centred care. The practice had an effective governance system in place, was well organised and actively sought to learn from previous inspections, performance data, complaints, incidents and feedback.
- The practice had clear and visible clinical and managerial leadership and supporting governance arrangements. There was a high level of constructive engagement with staff and all staff we spoke with told us they felt they were an integral part of the practice, they felt valued and safe during the pandemic.
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