Thursday, 29 June 2017

Theale Medical Centre "requires improvement" - CQC

Result of the inspection by the Care Quality Commission in March 2017:

Letter from the Chief Inspector of General Practice

We carried out a short notice announced comprehensive inspection at Theale Medical Centre on 15 and 24 March 2017. We rated the practice as good for providing Effective, Caring and Responsive services and requires improvement for Safe and Well Led. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
  • Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks and dispensary processes.
  • There was a leadership structure but not all staff felt supported by management. The practice sought feedback from patients, which it acted on.
  • Governance arrangements in respect to documentation and record keeping for organisational management were not always effective.
  • Staff were aware of current evidence based guidance. Most staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment. However, mental capacity act training was not offered to staff.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns. However, governance arrangements had not included logging all verbal complaints and staff told us many of these had been dealt with ineffectively or not responded to in a timely way.
  • Feedback from patients reported that access to a named GP and continuity of care was not always available quickly, although urgent appointments were usually available the same day.
  • Results from the national GP patient survey showed most patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
The areas where the provider must make improvement are:
  • The provider must ensure governance processes and systems are consistently applied in a timely manner to assess, monitor and improve the quality and safety of the services provided and in the management of risk. This includes ensuring that:
  • All staff are aware of policies and procedures and are effectively embedded in practice. For example, not all staff were aware of the whistleblowing policy and how to access it.
  • Governance arrangements include all necessary employment checks; training needs are met for all staff; dispensary governance processes identify risks and keep patients safe.
  • The complaints management processes include documenting and responding to all verbal complaints in a timely way. Learning and trends from complaints must be shared with all staff.
The areas where the provider should make improvements are:
  • Ensure all actions from the infection control audit have been documented.
  • Continue to review the learning disability register and offer health checks to improve outcomes for this patient group.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice


  1. The biggest problem at the surgery is making an appointment. Often when trying to book online I am offered just one appointment over a 4 week period.

    1. I can't usually book online at all because the earliest appointment with my GP is more than 30 daya away!