Archived: The Sandhurst Group Practice

Updated 27 June 2023

The Sandhurst Group practice is a two-site GP practice located in Berkshire at:

72 Yorktown Road

Sandhurst

Berkshire

GU47 9BT

The practice has a branch surgery at:

1 Cambridge Road

Owlsmoor

Sandhurst

Berkshire

GU47 0UB

The provider is registered with CQC to deliver the following Regulated Activities from both sites:

• Diagnostic and screening procedures.
• Family Planning.
• Maternity and midwifery services.
• Treatment of disease, disorder or injury.
• Surgical procedures.

The practice is situated within the Frimley Integrated Care System (ICS) and offers general medical services to approximately 18,500 patients as part of a contract held with NHS England. Services can be accessed from both the main practice and the branch surgery.

The practice is part of a wider network of GP practices called a Primary Care Network (PCN) which includes four GP practices and is called The Health Triange PCN.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the highest decile (10 of 10). The lower the decile, the more deprived the practice population is relative to others. According to the latest available data, the ethnic make-up of the practice area is, 92% White, 5% Asian, with the remainder of the patient population identifying themselves as Black, Mixed and Other ethnicities.

The age distribution of the practice population closely mirrors the local and national averages.

There is a team of 3 GP partners, 2 associate GP partners and 1 salaried GP who provide cover at both sites. The practice is a training practice but at the time of the inspection there were no GP registrars attached to the practice. The practice has a team of 4 nurses who provide nurse led clinics for long term conditions, 2 nursing associates and a trainee nurse apprentice. The clinical team also includes 1 healthcare assistant and 3 phlebotomists. The practice is supported by a team of reception, administration and secretarial staff. The practice manager role was vacant at the time of the inspection but there were 2 operations managers employed by the practice and the GP partners had agreed a contract with a team of external consultants to provide practice management services.

The practice is open between 8am to 6:30pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally by the practices’ PCN, The Health Triange, where late evening and weekend appointments are available. Out of hours services are provided by North Hampshire Urgent Care.

Updated 27 June 2023

In July 2022, we inspected the Sandhurst Group Practice and this led to enforcement action and an overall rating of inadequate. Under our inspection methodology, we inspected the practice in November 2022 to review the highest risks of concern included in our enforcement action but did not rate the practice. We carried out an announced comprehensive inspection at The Sandhurst Group Practice on 2 May 2023 to determine whether all the risks identified in our July 2022 inspection had been acted on and mitigated. We have provided a new overall rating for the location.

We rated the key questions as follows:

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led – requires improvement

Following our previous inspection in July 2022, the practice was rated inadequate overall, specifically inadequate for the provision of safe and well-led service and requires improvement for the provision of effective and responsive services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Sandhurst Group Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection of the Sandhurst Group Practice to follow up concerns and breaches of regulation which were identified at our inspection in July 2022. This was in line with our inspection priorities and because the practice is rated inadequate.

How we carried out the inspection.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing facilities.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A short site visit.
• Requesting patients to send us feedback about their experiences.

Our findings

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 and for the key questions of providing safe, effective, caring and responsive services. However, we rated the key question of providing well-led services requires improvement because we found:

• The practice had policies, systems and processes to receive and act on information from medicine safety alerts. However, these had not operated as effectively or consistently as the practice had intended.
• Systems and processes to manage prescription stationary existed but had not effectively allowed the practice to track and monitor stationary when in use.
• Coding of patient records had not always been completed when diagnostic test results indicated a diagnosis, for example diabetes.

We also found that:

• There was significant improvement in the effectiveness of patient care and treatment because patients with long term conditions received annual condition and medicine reviews in line with recommended national guidance, however these did not always follow a structured format.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• There was a system to record, make improvements and learn from incidents where things went wrong.
• The practice had clear oversight of staff compliance with mandatory training required by the practice and staff were up-to-date with training.
• There were systems and processes to manage clinical correspondence and incoming information when patients accessed care and treatment from other services.
• There were supervision arrangements and support for staff acting in role involving advanced clinical practice.
• The practice used feedback and data to identify improvements to patients’ experiences of care when accessing the service.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• There was a complaints process which operated effectively and complaints were analysed to identify themes and patterns.
• We found an improvement in the practice culture which encouraged openness, transparency and learning when systems and processes did not operate as intended.
• The leadership team had taken steps to identify the challenges for providing high quality, sustainable care and had developed a vision and strategy to address these challenges.

We found 1 breach of regulation. The provider must:

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

In addition, the provider should:

• Continue the action plan to improve the uptake of cervical screening appointments.
• Introduce a process which ensures patients with a do not attempt cardio pulmonary resuscitation record (DNACPR) have an annual review date recorded.

Following our inspection in July 2022 we placed The Sandhurst Group Practice into special measures. As a result of the findings of this inspection and the improvements made we have decided to remove the location from special measures.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care