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Review carried out on 24 April 2019

During an annual regulatory review

We reviewed the information available to us about Evergreen Practice on 24 April 2019. 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 15 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

In October 2014 we fund concerns related to the recruitment of staff during a comprehensive inspection of Evergreen Practice. Following the inspection the practice sent us an action plan detailing how they would improve recruitment and undertake necessary staff checks. We carried out desktop review of the Evergreen Practice on 15 July 2015 to ensure these changes had been implemented and that the practice was meeting regulations. Our previous inspection in October 2014 had found breaches of regulations relating to the safe delivery of services. The ratings for the practice have been updated to reflect our findings.

We found the practice had made improvements since our last inspection on 2 October 2014 and they were meeting the regulation relating to the recruitment of staff that had previously been breached.

Specifically the practice was:

  • Operating safe systems in relation to the recruitment of staff.

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 02/10/2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Evergreen Practice is located in a large health centre in an urban area. It provides primary medical services to approximately 3500 registered patients.

We visited the practice location at Skimped Hill Health Centre, Skimped Hill Lane, Bracknell, Berkshire RG12 1LH  

We spoke with seven patients and eight staff during the inspection. This was the first inspection since registration. The announced, comprehensive inspection at Evergreen Practice took place on 2 October 2014.

Evergreen practice was rated as good overall.

Our key findings were as follows:

  • The practice is rated as requires improvement for safety. The practice had systems in place to report, investigate and respond to incidents and there was some  evidence to demonstrate shared learning across all practice staff relating to incidents and complaints. We found recruitment checks were not documented in accordance with the practice policies and current regulations.  We found the practice operated from clean, well maintained premises.
  • The practice is rated as good for effective. Patient outcome data was good. GPs treated patients in accordance with national and local guidelines.  Staff were trained and knowledgeable. The practice worked with other services to ensure patients with complex needs were cared for appropriately.
  • The practice is rated as good for caring. Feedback from patients and survey data showed the practice performed above the clinical commissioning group (CCG) and national average on patient satisfaction.
  • The practice is rated as good for responsive. there was an accessible complaints system with evidence demonstrating that the practice responded quickly to issues raised and shared learning across practice staff. Patients we spoke with and survey data demonstrated patients were very satisfied with access to the practice for urgent and routine appointments.
  • The practice is rated as good for well-led. The senior GP had a clear vision for the development of the practice and staff were confident in the leadership of the GP. The practice had an active patient participation group (PPG). Staff had received induction, regular performance reviews and were supported in their roles.

There was one area of practice where the provider needs to make improvements. 

Importantly, the provider must:

  • Ensure that all the recruitment checks are carried out and recorded as part of the staff recruitment process

In addition the provider should:

  • The practice should ensure governance arrangements are formalised including lines of management and accountability.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice