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Inspection carried out on 14 June 2019

During an inspection to make sure that the improvements required had been made

We carried out an announced focused inspection at Finchampstead Surgery on 14 June 2019. This inspection was carried out due to the commission receiving information of concern. This report covers our findings in relation to those concerns.

The full comprehensive report on the previous inspections can be found by selecting the ‘all reports’ link for Finchampstead Surgery on our website at .

The practice is rated as good overall. We did not rate the practice following this focused inspection.

Our key findings were as follows:

  • Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
  • Staff worked together and with other organisations to deliver effective care and treatment.

However, the provider should:

  • Ensure all patients with a Do Not Attempt Cardio-pulmonary Resuscitation order in place have an initial assessment fully documented.

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 We have not revisited The Finchampstead Surgery as part of this review because they were able to demonstrate that they were meeting the standards without the need for a visit.

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

During our comprehensive inspection of The Finchampstead Surgery in February 2016 we found a range of concerns. These resulted in the practice being rated as requires improvement for the provision of safe, effective and well led services.

Specifically we found the practice:

  • Did not have appropriate systems in place to ensure the security of prescriptions.

  • Had not completed actions identified in their fire risk assessment.

  • Had not assured themselves that all staff had received relevant immunisations to keep patients and staff safe.

  • Had nationally reported outcomes for patients with long term conditions that were below average. Patients with these conditions may not have been receiving the reviews of their treatment to ensure their care was maintained.

  • Did not keep all policies and procedures relevant to the management and safety of the practice reviewed and up-to-date.

The practice sent us an action plan setting out how the changes they were making to address the issues that led to our concerns.

We carried out a desktop review commencing on 19 October 2016 to ensure these changes had been implemented and that the service was meeting regulations. The ratings for the practice have been updated to reflect our findings. We found the practice had made improvements in effective provision of services since our last inspection on 16 February 2016 and they were meeting the requirements of the regulations in breach.

Specifically the practice had:

  • Introduced stricter controls in monitoring prescriptions and enhanced the security of rooms where blank prescriptions were held.

  • Completed the actions identified in their fire risk assessment.

  • Ensured that staff had received the relevant immunisations to reduce the risk of infection to both patients and other staff.

  • Improved their systems to complete reviews of the care of patients with long term conditions. The practice provided unverified data for the first six months of the recording period in 2016/17. This showed improved outcomes for these patients.

  • Had updated all policies and procedures in accordance with the practice review programme.

We have updated the ratings for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective and well led services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 16 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Finchampstead Surgery on 16 February 2016. Overall the practice is rated as requires improvement.

Specifically we found the practice good for the provision of caring and responsive services. Although it is rated as requires improvement for the provision of safe, effective services and well led services and this led to the overall rating of requires improvement. The overall rating applies to all population groups.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Patients said they were treated with compassion, dignity and respect.
  • 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 had good facilities and was well equipped to treat patients and meet their needs.
  • Audits had been carried out and we saw evidence that audit was driving improvement in performance to improve patient outcomes.

  • The practice had proactively sought feedback from patients and had an active patient participation group.
  • The provider was aware of and complied with the requirements of the Duty of Candour.
  • The provider had appointed a care coordinator who worked with patients who had been discharged from hospital. This member of staff assisted patients accessing voluntary and statutory support to help prevent further admission to hospital.

However;

  • Systems to manage risks to patients were operated inconsistently. For example, actions identified from the practice fire risk assessment had not been completed.
  • Data showed outcomes for patients with long term conditions were consistently low compared to the locality and nationally. The data showed the practice below average in 13 out of 19 monitored conditions.
  • The practice had a number of policies and procedures to govern activity, but it was not clear when some were due for review.
  • Consulting and treatment rooms were left unlocked and open during the day. Unauthorised access could have been gained leaving prescriptions and equipment vulnerable.

The areas where the provider must make improvements are:

  • Ensure the immunisation status of clinical staff is recorded.

  • Ensure the actions identified in the fire risk assessment are completed.
  • Ensure the number of reviews for patients with long term conditions is increased and the outcomes of the reviews are appropriately and accurately recorded in the patient’s medical records.
  • Improve the security of clinical rooms during the working day to ensure prescriptions are kept safely. 

  • Maintain a programme of review of policies and procedures  used to govern the activity of the practice.

The areas where the provider should make improvements are:

  • Introduce a timetable for checking electrical equipment is safe for use.
  • Promote the availability of chaperones.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice