We previously carried out an announced comprehensive inspection at Henley Green Medical Centre on 10 January 2017. Following this inspection, we rated the practice as requires improvement overall, with requires improvement ratings for all patient population groups.

We subsequently carried out a further inspection on 26 September 2017. Following this inspection, we rated the practice as good overall, with good ratings for all patient population groups.

We carried out an announced comprehensive inspection at Henley Green Medical Centre on 5 February 2019 as part of our inspection programme. The provider had changed from a partnership to a sole provider since the most recent previous inspection in September 2017. As a result, this was the first inspection we have carried out of the sole provider.

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.

We have rated this practice as requires improvement for providing effective services. The practice had not identified and implemented sufficient actions to improve outcomes that were below average for some population groups.

People with long-term conditions; families, children and young people; and people experiencing poor mental health (including people with dementia) were rated as requires improvement. All other population groups were rated as good.

We have rated the practice as requires improvement for providing effective services because:

• The practice had not identified and implemented sufficient actions to improve sustained outcomes for certain population groups. This included people with long-term conditions; families, children and young people; and people experiencing poor mental health (including people with dementia).
• The practice had not identified and implemented actions to address childhood immunisation uptake rates, which were below World Health Organisation (WHO) targets.
• The practice had not identified and implemented actions to address cancer screening rates, which were below local and national averages.

We have rated the practice as good for providing safe, caring, responsive and well-led services because:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines and best practice.
• There were comprehensive policies and procedures to support best practice, and these were regularly reviewed and updated.
• There was an open and transparent approach to safety and a system in place for recording, reporting and learning from significant events. The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• There were clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse, and for identifying and mitigating risks to health and safety.
• There were clear responsibilities, roles and systems of accountability to support effective governance.
• Patient feedback was in line with regional and national averages.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• The practice had sought support from the local Clinical Commissioning Group (CCG) and had engaged with other stakeholders to improve performance and outcomes.

Whilst we found no breaches of regulations, the provider should:

• Identify and implement actions to improve performance for people with long-term conditions; families, children and young people; and people experiencing poor mental health (including people with dementia).
• Identify and implement actions to improve the uptake for childhood immunisation.
• Identify and implement actions to improve cancer screening rates.

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