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Inspection carried out on 3 December 2019

During a routine inspection

We carried out an announced comprehensive inspection at Mortimer Surgery in November 2018 where we rated the practice as requires improvement for providing safe and well-led services and good for providing effective, caring and responsive services. They were rated as requires improvement overall. We undertook this inspection on 3 December 2019 to check the appropriate improvements had been made.

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.

We have rated this practice as good overall and good for all population groups.

We found that:

  • The practice had taken appropriate action and responded to the concerns we identified during our previous inspection of the previous provider.
  • The practice had improved the governance arrangements.
  • The practice provided effective care and treatment.
  • Patient feedback was positive about staff. We received 27 CQC comments cards, with 27 of the comments being positive overall.
  • The practice was responsive to individual patients’ needs.

Whilst we found no breaches of regulations the practice should:

  • Review the arrangements for the monitoring of staff compliance with standard operating procedures.

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 27/11/2018

During a routine inspection

We carried out an announced comprehensive inspection at Mortimer Surgery on 27 November 2018 as part of our inspection programme. Our inspection team was led by a CQC inspector and included a GP specialist advisor and an inspection manager.

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 services and information from the provider, patients, the public and other organisations.

This practice as rated as requires improvement overall.

We concluded that:

  • Patients were supported, treated with dignity and respect and were involved as partners in their care.
  • People’s needs were met by the way in which services were organised and delivered.

However, we also found that:

  • People were not always adequately protected from avoidable harm and abuse.
  • 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 Disclosure and Barring service checks are carried out in accordance with the practice policy.
  • Ensure exception reporting for diabetes and mental health is monitored and work undertaken to improve uptake.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

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

Inspection carried out on 12 August 2015

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection of the Mortimer Surgery, 72 Victoria Road, Mortimer Common, Reading, Berkshire, RG7 3SQ on 12 August 2015. We carried out this inspection to check that the practice had made improvements and were meeting regulations. Our previous inspection in November 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 significant improvement since our last inspection in November 2014 and they were meeting regulations that had previously been breached.

In August 2015 we found concerns which led us to issue requirement notices to this practice. The concerns were:

  • Not all recruitment and employment information required by the regulations was documented in all staff members’ personnel files.
  • Medicine management and dispensing systems were not reviewed and did not reflect national guidelines.

Following the inspection the practice sent us an action plan detailing how they would improve and address the concerns we identified. We found the practice had made improvements since our last inspection on 12 November 2014 and they were meeting the regulations relating to the recruitment of staff and management of medicines that had previously been breached.

Specifically the practice:

  • Operated safe systems in relation to the recruitment of staff.
  • Changed their management and monitoring of medicines to improve safety
  • Increased staffing in the dispensary

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.

However there is an area the provider should consider making further improvements:

  • Ensure the dispensary staff have the necessary skills and ongoing training to perform their roles appropriately.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 12 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We undertook a comprehensive inspection of Mortimer Surgery on the 12 November 2014. Overall we have rated the practice as good. The practice was rated requires improvement in safe and good in the other four domains.

Our key findings were as follows:

Generally the feedback from patients was very positive. Patients we spoke with said they were very happy with the service they received. Patients were complimentary of the practice staff. Most patients were happy with the appointment system and all knew they could speak to a doctor or a nurse over the phone whenever they needed to.

We found medicine management systems did not always follow national guidance. We found some of the recruitment information required by within regulation was not recorded in the individual staff files.

The results from the national GP survey showed, 88% of patients said the last appointment they booked was convenient. Eighty eight per cent of patients said the last GP the spoke with was good at giving them enough time and 80% of patients were able to get an appointment to see a GP or nurse the last time they tried.

Patients’ needs were assessed and care was planned and delivered in line with current legislation. This included assessing capacity and promoting good health.

We found the service was responsive to patient’s needs. Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.

The practice is well-led. It had a clear vision and strategy. Staff were clear about the vision and their responsibilities in relation to this. There was a clear leadership structure and staff felt supported by management.

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

Importantly, the provider must:

  • Ensure all recruitment and employment information required by the regulations are documented in all staff members’ personnel files.
  • Ensure medicine management and dispensing systems are reviewed and reflect national guidelines.

In addition the provider should:

  • Ensure all the dispensing team receive regular support with professional development and appropriate training.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice