Letter from the Chief Inspector of General Practice

Following a comprehensive inspection of Green Meadows Partnership, Ascot, Berkshire in June 2015, the practice was given an overall inadequate rating and a decision was made to place the practice in special measures.

The practice was rated inadequate in the safe and well-led domains, requires improvement in the effective and responsive domains and good in the caring domain. In addition, all six population groups were rated as inadequate.

This provider had been inspected thrice before in February 2014, September 2014 and June 2015. On all three previous inspections we found that the practice was not meeting all the essential standards of quality and safety.

When the practice was inspected in February 2014 we identified breaches in the regulations relating to safeguarding, cleanliness and infection control and assessing and monitoring the quality of service provision.

We undertook a follow up inspection in September 2014 to review the previous breaches in regulations. We found the provider had not acted upon the information provided to them in February 2014 and further breaches were found in relation to cleanliness and infection control and assessing and monitoring the quality of service provision.

Following a comprehensive inspection in June 2015, the practice was given an overall inadequate rating and a decision was made to place the practice in special measures

We carried out an announced comprehensive inspection at Green Meadows Partnership on 11 February 2016, to consider whether sufficient improvements had been made. The provider had addressed the concerns we had at the previous three inspections (February 2014, September 2014 and June 2015). Overall the practice is rated as good at this inspection.

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

• The practice had a clear vision that had improvement of service quality and safety as its top priority. The practice fully embraced the need to change, high standards were promoted and there was good evidence of team working.

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

• Risks to patients were assessed and well managed, this included recruitment checks and completed actions following infection control concerns we identified at the June 2015 inspection.

• Feedback from patients about their care was consistently and strongly positive. However, not all patients were satisfied with telephone access to the practice.

• Nationally reported Quality and Outcomes Framework (QOF) data, for 2014/15, showed the practice had performed below the local Clinical Commissioning Group and national averages in obtaining points available to them for providing recommended care and treatment to patients. The practice maintained a comprehensive understanding of the performance and we saw areas of low performance specifically diabetes and mental health indicators had been reviewed and action plans implemented.

• Staff were consistent in supporting patients to live healthier lives through a targeted and proactive approach to health promotion.

• We found there was good staff morale in the practice, with high levels of team spirit and motivation. There was a strong learning culture evident in the practice. This came across clearly through discussions with staff members.

• It was evident the practice had gone through a period of transition including the implementation of a new management team. There was now a clear leadership structure and staff felt supported by management.

However, there were areas where the practice needs to make improvements. Importantly the provider should:

• Improve patient outcomes through the measures of the Quality and Outcomes Framework. (QOF, is a system intended to improve the quality of general practice and reward good practice). Specfically, diabetes and mental health (including dementia) outcomes.

• Continue to review and improve how telephone calls are handled by the practice to ensure patients are able to contact the practice without difficulty.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Green Meadows Partnership on 17 June 2015. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing safe services and being well led. The population groups for older people, people with long term conditions, families children and young people, working age people, people whose circumstances may make them vulnerable and people experiencing poor mental health were rated as inadequate based on the overall rating of the practice. Improvements were also required for providing responsive and effective services. The practice was rated as good for providing a caring service.

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

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment and actions identified to address concerns with infection control practice had not been taken.

• The practice did not have robust governance arrangements to effectively manage risks to protect patients from harm and improve the quality of services provided.

• The practice had no clear leadership structure, insufficient leadership capacity and in effective governance arrangements.

• Patient outcomes are average for the locality. Patients' needs are assessed and audits had taken place.

• Patients said that they are treated with compassion, respect and dignity and are involved in decisions about their care and treatment.

The areas where the provider must make improvements are:

• Review recruitment arrangements to include all necessary employment checks are undertaken for all staff and appropriate records kept.

• Develop a structured induction training programme for all new staff.

• Support all staff at the practice to provide individual feedback such as appraisal.

• Implement the systems to assess and manage the risks of health related infections. For example, ensuring patients, staff and visitors are protected from the risk of water borne infection by means of completing a legionella risk assessment.

• Ensure there are formal governance arrangements in place and staff are aware how these operate to ensure the delivery of safe and effective services.

• Ensure all staff have access to appropriate policies, procedures and guidance to carry out their role, such as information about whistleblowing .and safeguarding.

• Implement effective systems to identify, assess, and manage risks relating to the health, welfare, and safety of patients, and others who may be at risk.

• Ensure there are mechanisms in place to seek feedback from staff and verbal feedback from patients is recorded. To ensure the practice is responsive to patient feedback and staff views on improving the service.

• Ensure there are formal arrangements in place and staff are aware how these operate to ensure the security of prescriptions in accordance with national guidance.

In addition the provider should:

• Ensure all members of staff are aware of how to locate the practice’s safeguarding policies and the telephone numbers and names of people to ring should they have urgent safeguarding concerns.

On the basis of the ratings given to this practice at this inspection and the concerns identified at the two previous inspections in February 2014 and September 2014 the provider has been placed into special measures. This will be for a period of six months when we will inspect the provider again. Special measures is designed to ensure a timely and coordinated response to practices found to be providing inadequate care.

Being placed into special measures represents a decision by CQC that a practice has to improve within six months to avoid having its registration cancelled.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

When we visited Green Meadows partnership in February 2014 we found the practice was not meeting all safety and quality requirements of the Health and Social Care Act 2008. Suitable arrangements were not in place to safeguard patients from the risk of abuse. Current guidance to reduce the risk and spread of infection was being followed in full and quality assurance systems were not operated effectively. For example a control of infection audit to identify, assess and manage risks had not been completed. The provider sent us a plan setting out the actions they would take to address these issues. We carried out this visit to check the actions had been taken.

During this visit we spoke with one GP, the practice manager, two practice nurses and three members of administration staff. We saw progress to address the issue of safeguarding. However, we found measures to identify, assess and manage the risk of infection were not effective and some other quality assurance systems were not effective.

We found training had been taken by staff in safeguarding both adults and children. The risk of abuse going unnoticed and unreported had been reduced.

Some rooms in the practice were dirty. Monitoring of cleaning standards was not effective. Control of infection audits required by current guidance had not been carried out. The risk of cross infection had not been assessed or managed.

Patients told us the staff at Green Meadows Partnership treated them with respect and dignity. They said clinical staff explained medical conditions and treatment clearly and gave patients the time they needed during consultations. One patient said their GP was "very thorough" and was "generous with time".

Patient records included notes on patient consultations, medical histories and significant health information was clearly displayed. This enabled staff to review appropriate information when assessing patients' needs. Patients told us appointments for assessment or treatment of specific conditions were planned and they were prompted to come to the practice when necessary. One patient said "We got an SMS about the baby clinic." Another said "I get prompted (to visit the practice) for one thing." Patients told us it was difficult to make appointments on the same day.

The practice had safeguarding policies for staff to refer to. However, the service did not ensure staff reviewed these policies and did not ensure staff had appropriate awareness of safeguarding.

The practice did not have effective systems to monitor cleanliness and infection control risks. There was inadequate monitoring of risks related to the care and welfare of patients and others who may be at risk.

We reviewed the information available to us about Green Meadows Partnership on 30 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.