We carried out an announced focused inspection at Staines Thameside Medical on 29 March 2019. This was to follow up on a breach of regulations identified at our previous inspection. At our previous inspection on the 6 November 2018 we found that the provider did not demonstrate they had acted where risks were identified. We issued a warning notice regarding these risks. The details of these can be found by selecting the ‘all reports’ link for Staines Thameside Medical on our website at www.cqc.org.uk.

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

This practice remains rated as good overall and requires improvement for providing safe services.

At this inspection we found the practice had made some improvement but was not fully compliant with the warning notice; in particular;

• The practice had updated protocols in relation to managing infection prevention and control.
• The practice had up to date risk assessments in relation to fire safety issues. However the practice had not completed actions identified by these risk assessments and had no plan to do so.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.

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

This practice is rated as Good overall. (Previous rating October 2017 – Good overall and in all domains with the exception of safe which was rated as required improvement)

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

We carried out an announced focused inspection at Staines Thameside Medical on 6 November 2018. This was to follow up on a breach of regulations identified at our previous inspection. At our previous inspection on the 4 October 2017 we found that the provider did not demonstrate they had taken action where risks were identified and there was no documented evidence that learning from incidents and significant events was shared. The details of these can be found by selecting the ‘all reports’ link for Staines Thameside Medical on our website at www.cqc.org.uk.

At this inspection we found:

• Annual infection control audits were undertaken and we saw evidence that some action had been taken to address the risks identified. We saw that the practice had not taken steps to mitigate all of the risks identified.
• Some fire risk assessments had been undertaken.
• The practice carried out analysis of significant events and shared the learning with colleagues.

The areas where the provider must make improvements as they are in breach of regulations are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

At our previous comprehensive inspection at Staines Thameside Medical on 11 May 2016 we found a breach of regulation relating to the provision of safe and effective services. The overall rating for the practice was requires improvement. Specifically, the practice was rated requires improvement for the provision of safe and effective services and good for the provision of caring, responsive and well-led services. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Staines Thameside Medical on our website at www.cqc.org.uk.

This inspection was carried out on 4 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in May 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. We found the practice had made some improvements since our last inspection. Using information provided by the practice we found the practice was now meeting the regulations that had previously been breached for effective services. However, further improvements are required for safe services. We have amended the rating for this practice to reflect these changes. The practice is now rated good for the provision of effective, caring, responsive and well led services and requires improvement for safe services.

Our key findings were as follows:

• Annual infection control audits were undertaken and we noted that action had not been taken to address all the improvements identified as a result.
• We reviewed three personnel files and found all appropriate recruitment checks had been undertaken prior to employment.
• Fire risk assessments had been undertaken, however not all actions had been completed.
• The practice carried out analysis of significant events and verbally shared the learning with colleagues. However, as clinical meetings had ceased since February 2017 there was no documented evidence of this.
• The practice used the information collected for the Quality and Outcomes Framework (QOF) and performance against national screening programmes to monitor outcomes for patients. (QOF is a system intended to improve the quality of general practice and reward good practice). Various actions had been taken to improve areas of low performance. We saw these actions had been successful as the most recent results indicated performance for the vast majority of clinical indicators had improved when compared with the previous year’s performance.
• Staff had the skills, knowledge and experience to deliver effective care and treatment and had completed training appropriate to their job role.
• The practice’s uptake for the cervical screening programme had significantly increased since the previous year.

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

Importantly, the provider must:

• Ensure care and treatment is provided in a safe way to patients

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 Staines Thameside Medical on 11 May 2016. Overall the practice is rated as requires improvement.

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

• The practice was affected by the substantial flooding of the river Thames in 2014, which resulted in the practice offering reduced GP services from the practice and three other nearby locations for just over a week.The practice remained focused on continuing to provide care and treatment to their patients during this challenging time, particularly those that were most vulnerable.
• There was an open and transparent approach to safety and staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were not always recorded thoroughly enough.
• Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks, training, appraisals, fire safety and infection control.
• Data showed patient outcomes were low compared to the national average.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a named GP and 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.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.
• The practice had a number of policies and procedures to govern activity, but some were overdue a review.

The areas where the provider must make improvements are:

• Ensure recruitment arrangements include all necessary employment checks for all staff.
• Review and update procedures and guidance.
• Ensure training appropriate to job role is completed by all staff.
• Review the fire risk assessment and ensure all actions are completed and that all staff receive fire safety awareness training.
• Ensure that clinical waste bins that are lidded and foot pedal operated are provided in every clinical room in a position that is easily accessible to staff.

In addition the provider should:

• Review and improve care for patients with long term conditions, and uptake of national screening and immunisation programmes.
• Review and improve the system for planning and recording meetings including recording the sharing of lessons learned from significant events.
• Ensure that actions identified by infection control audits are completed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice