• Doctor
  • GP practice

Theale Medical Centre

Overall: Good read more about inspection ratings

Englefield Road, Theale, Reading, Berkshire, RG7 5AS (0118) 930 2513

Provided and run by:
Theale Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Theale Medical Centre on 6 July 2023. 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 Theale Medical Centre, you can give feedback on this service.

24 November 2021

During a routine inspection

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.

This included:

  • 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.

Our findings

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

16 July 2019

During an inspection looking at part of the service

We carried out an announced comprehensive inspection of the practice on 27 February and 5 March 2019 as part of our inspection programme and the practice was rated as require improvement overall. They were rated as requires improvement for providing safe and effective services, good for providing caring and responsive care and inadequate for being well-led. We issued a Warning notice for regulation 17, Good governance, as a result of this inspection.

This inspection, undertaken on 16 July 2019, was a focused inspection to review the areas of concern highlighted in the warning notice.

The practice remains rated as follows, until our next comprehensive inspection:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Inadequate

At this inspection we concluded that:

  • The practice had established effective systems and processes to ensure recall systems for long-term conditions, supervision of clinical staff and summarisation of patient notes were actioned appropriately.
  • The provider had met the requirements of the Warning notice and had made improvements to governance.

At this inspection we found that improvements had been made to the practice’s governance systems. We were satisfied that sufficient progress against the warning notice had been made.

We will undertake a further comprehensive inspection in line with our current methodology to ensure the practice has made the necessary improvements detailed in the February and March 2019 report.

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

27 February 2019 and 5 March 2019

During a routine inspection

We carried out an announced comprehensive inspection of the practice on 27 February and 5 March 2019 as part of our inspection programme. The practice was previously inspected in March 2017, with an overall rating of requires improvement, as safe and well-led were rated as requires improvement. A follow up inspection was undertaken in October 2017 and the practice was rated as good overall.

Our judgement of the quality of care at this service is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about the service and information from the provider, patients, the public and other organisations.

The practice is rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Inadequate

This practice is rated as requires improvement overall.

We concluded that:

  • The practice had clear systems, practices and processes to keep people safeguarded from abuse.
  • Patients were supported, treated with dignity and respect and were involved as partners in their care.

However, we also found that:

  • The practice did not always have systems to keep people safe.
  • People’s needs were not always met by the way in which services were organised and delivered.
  • The delivery of high quality care was not always assured by effective governance procedures.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Ensure systems for monitoring cervical screening outcomes are fully embedded and effective.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

25 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 Theale Medical Centre on 15 & 24 March 2017. The overall rating for the practice was requires improvement. Specifically, the practice was found to be requires improvement for safe and well led services and good for providing effective, caring and responsive services. The full comprehensive report on the March 2017 inspection can be found by selecting the ‘all reports’ link for Theale Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 25 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in March 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Our key findings were as follows:

  • The practice had reviewed and updated their governance processes to ensure risks were identified and resolutions implemented quickly and consistently. Active monitoring procedures were in place to mitigate risks.
  • Practice staff told us communication between practice management and non-clinical staff had improved and they felt more supported and involved in decisions about how the practice was run.
  • Staff had been made aware of up to date policies and procedures. Staff had appropriate knowledge demonstrating the practice policies were embedded.
  • Governance arrangements for recruitment checks, staff training and dispensary processes had improved.
  • The practice had reviewed the governance arrangements for dealing with verbal complaints. The complaints log demonstrated verbal complaints were dealt with in timely way and were regularly reviewed to ensure actions had been taken.
  • An action plan for infection control audit outcomes had been documented to ensure actions had been completed.
  • The practice had encouraged patients on the learning disability register to attend for health checks and had improved the number of patients receiving these.

At our follow up inspection the practice was rated as good for safe and well led services. The population groups have also been rated good. Overall the practice is now rated as good.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

15 & 24 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a short notice announced comprehensive inspection at Theale Medical Centre on 15 and 24 March 2017. We rated the practice as good for providing Effective, Caring and Responsive services and requires improvement for Safe and Well Led. Overall the practice is rated as requires improvement.

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

  • Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks and dispensary processes.
  • There was a leadership structure but not all staff felt supported by management. The practice sought feedback from patients, which it acted on.
  • Governance arrangements in respect to documentation and record keeping for organisational management were not always effective.
  • Staff were aware of current evidence based guidance. Most staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment. However, mental capacity act training was not offered to staff.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns. However, governance arrangements had not included logging all verbal complaints and staff told us many of these had been dealt with ineffectively or not responded to in a timely way.
  • Feedback from patients reported that access to a named GP and continuity of care was not always available quickly, although urgent appointments were usually available the same day.
  • Results from the national GP patient survey showed most patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvement are:

  • The provider must ensure governance processes and systems are consistently applied in a timely manner to assess, monitor and improve the quality and safety of the services provided and in the management of risk. This includes ensuring that:
  • All staff are aware of policies and procedures and are effectively embedded in practice. For example, not all staff were aware of the whistleblowing policy and how to access it.
  • Governance arrangements include all necessary employment checks; training needs are met for all staff; dispensary governance processes identify risks and keep patients safe.
  • The complaints management processes include documenting and responding to all verbal complaints in a timely way. Learning and trends from complaints must be shared with all staff.

The areas where the provider should make improvements are:

  • Ensure all actions from the infection control audit have been documented.
  • Continue to review the learning disability register and offer health checks to improve outcomes for this patient group.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

30 September 2015

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

Our previous inspection in November 2014 found breaches of regulations relating to the safe delivery of services.

We found the practice required improvement for the provision of safe services, and was rated good for providing effective, caring, responsive and well-led services. The population groups were rated as good for the patients registered at the practice.

This inspection was undertaken to check the practice was meeting regulations. For this reason we have only rated the location for the key questions to which these relate. This report should be read in conjunction with the full inspection report of 26 November 2014.

We found the practice had made improvements since our last inspection. At our inspection on the 30 September 2015 we found the practice was meeting the regulations that had previously been breached.

Specifically we found:

  • Improvements had been made to maintain the accurate records of patients information. For example home visits had been properly recorded to ensure other staff would be able to access an accurate record of patients most recent care and treatment.
  • The practice had instituted systems to manage medicines and nomad or blister packs were checked by a second member of staff.
  • Staff were complying with the practice control of infection policy.
  • The practice was actively identifying, assessing and managing risks to health and safety of patients, staff and visitors.

We have amended the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

26 November 2014

During a routine inspection

Theale Medical Centre is located in purpose built premises in West Reading. There are approximately 10,700 patients registered at the practice. We carried out an announced comprehensive inspection of the practice on 26 November 2014 and we visited Theale Medical Centre. This was the first inspection of the practice since registration with the CQC. There is a branch practice called Calcot Surgery, 72a Royal Avenue, Calcot, Reading, RG31 4UR which we did not visit as part of this inspection.

Theale Medical Centre is a purpose built. Adaptations have been made to ensure the practice is accessible. The local community has areas of deprivation and the staff were aware of the needs of this section of the population. The appointment system allows advanced appointments to be booked. Urgent appointment slots were also available. Patients told us they were able to make appointments when they needed them, although some patients told us they needed to wait too long for an appointment. Patients told us staff were caring, friendly and considerate.

We spoke with nine patients during the inspection. We met the chair person of the Patient Participation Group, five GP’s the practice manager, reception manager, one member of the nursing team and administration staff.

Theale Medical Centre practice was rated good overall.

Our key findings were as follows:

The practice mostly maintained a safe environment but there were concerns about the management of medicines and staff recruitment. Patients with health conditions were well cared for and national data placed the practice above the national average for caring for long term conditions. Some elements of patient records were not always completed to ensure safety in the delivery of their care. Patients told us the practice was caring, accessible and they felt well supported. The practice was in a state of transition where processes and procedures were being changed. The leadership were proactive in assessing and planning for future demands on the practice.

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

The provider must:

  • ensure policies, procedures and monitoring tools such as safeguarding policies, training records and infection control tools are consistent, suitable for their purpose and accessible.
  • amend and monitor the processes for dispensing and storing medicines.
  • implement a fire risk assessment for all the practice’s premises

We have issued compliance actions for Management of Medicines and Assessing and Monitoring the Quality of Service provision.

In addition the provider should:

-monitor the use of cleaning equipment to ensure it is used in designated areas of the practice.

- undertake a legionella risk assessment to determine what action may be required to reduce any risk of infection

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice