The Care Quality Commission
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Archived: The Sandhurst Group Practice

Overall: Good read more about inspection ratings

72 Yorktown Road, Sandhurst, Berkshire, GU47 9BT (01252) 877322

Provided and run by:
The Sandhurst Group Practice

All Inspections

2 May 2023

During a routine inspection

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

7 November 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at The Sandhurst Group Practice on 7 November 2022 to determine if improvements had been made following our previous inspection in July 2022 which led to enforcement action. This inspection was to determine whether the concerns of highest risk identified at the last inspection had been acted on or were being managed and mitigated. We did not provide a rating as a result of this inspection.

We inspected The Sandhurst Group Practice in July 2022 and rated them inadequate overall. As a result of that inspection we issued one warning notice and two requirement notices which required the practice to make improvements. However, this inspection only reviewed concerns specified in the warning notice.

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 to follow up a breach of Regulation 17: Good governance, under the Health and Social care Act 2008 (Regulated Activities) Regulations 2014.

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.

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.

We found that:

  • The system to receive and act upon medicine safety alerts from the Medicines and Healthcare products Regulatory Agency had been improved and was being operated effectively.
  • A system and process to ensure the competence and supervision of non-medical prescribers had been introduced and was being used to monitor prescribing practices more safely.
  • The system to monitor urgent referrals for patients with possible symptoms of cancer had been reviewed and was being operated effectively.
  • Patients with mental health conditions had appropriate plans for their care in place and referrals where made where necessary.
  • There was an improved system to seek feedback from patients and staff.
  • The practice had continued to progress their action plan to improve access to appointments for patients.
  • Improvements had been made to the complaints system and processes existed to ensure it operated in accordance with practice policy.
  • The practice had implemented a new system to review what had happened when things went wrong, identify learning and share the outcome with staff.
  • Health and safety systems and processes had improved but associated action plans to mitigate all risk had not been completed by the practice’s identified target date.

In addition the provider should:

  • Continue the action plan to improve access for patients.
  • Continue to seek feedback from staff and patients to improve the quality and effectiveness of services, and identify appropriate ways to improve.
  • Revise the actions plans in place mitigating the health and safety risks in both buildings to guarantee prompt completion.
  • Complete the action plan for safeguarding training for all staff, including locums.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

15 July 2022

During a routine inspection

We carried out an announced inspection at The Sandhurst Group Practice on 15 July 2022. Overall, the practice is rated as Inadequate.

We rated the following key questions as:

Safe - Inadequate

Effective – Requires improvement

Caring - Good

Responsive – Requires improvement

Well-led - Inadequate

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

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit to both the main practice and branch practice
  • Speaking with members of the Patient Participation Group
  • Obtaining patient feedback from external sources

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 Inadequate overall.

We found that:

  • The practice did not always provide care in a way that kept patients safe and protected them from avoidable harm.
  • The practice did not have clear systems, practices and processes to keep people safe and safeguarded from abuse.
  • The system for identifying and mitigating risks relating to infection prevention and control at the practice were not always effective and there were gaps in staff training relating to infection prevention and control.
  • Recruitment gaps meant there was not always enough staff to cover appointments, staff worked excessive hours and there was a backlog of new patient notes requiring summarising, test results and clinical correspondence.
  • There was a lack of oversight and monitoring of referrals.
  • The practice did not ensure all medicines were prescribed safely to patients or reviewed appropriately.
  • The practice did not have an effective system to learn and make improvements when things went wrong.
  • Some patients with long term conditions were not having their conditions managed appropriately.
  • The practice did not have an effective system in place to manage incoming information about patients in relation to patients care and treatment from other services.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice respected patients’ privacy and dignity.
  • Patients were not always able to access care and treatment in a timely way.
  • Complaints were not used to improve the quality of care.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice systems and processes for acting on medicine safety alerts had not ensured prescribing was monitored effectively and in line with guidance.
  • There was a lack of oversight of staff training and we found significant gaps in training for clinical and non-clinical staff.
  • Leaders could not demonstrate they had the capacity and skills to deliver high quality sustainable care.
  • The overall governance arrangements were ineffective.
  • The practice did not always act on appropriate and accurate information.
  • There was limited evidence of systems and processes for learning, continuous improvement and innovation.

We found three breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.

In addition, the provider should:

  • Ensure all nurses are correctly authorised to administer medicines under Patient Group Directions (PGDs).
  • Continue to work to improve the uptake of screening and immunisations.
  • Improve staff awareness of the role of freedom to speak up guardian.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

2 July 2015

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection of the Sandhurst Group Practice, 72 Yorktown Road, Sandhurst, Berkshire,GU47 0BT on 2 July 2015. We carried out this inspection to check that the practice was meeting regulations. Our previous inspection in October 2014 had found breaches of regulations relating to safe and effective delivery of services. The ratings for the practice have been updated to reflect our findings.

We found the practice had made significant improvement since our last inspection on 2 October 2014 and they were meeting regulations that had previously been breached.

Specifically the practice was:

  • Operating safe systems in relation to the recruitment of staff and there was evidence of a systematic approach to staff induction.
  • Following processes to manage medicines safely and cleaning and infection control procedures had been improved to reduce risk of cross infection.
  • Consistently applying current clinical guidelines and had undertaken a range of clinical audits to assess, monitor and improve patient care.

We have changed the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective, caring, responsive and well led services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

2 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We undertook a comprehensive inspection of The Sandhurst Group practice on 2 October 2014. During the inspection our team visited both the Owlsmoor and Sandhurst practice’s because both are registered with the CQC.

The practice is rated as requires improvement across both practice sites. We found evidence of weaknesses in the operation of safety systems and improvements must be made. Systems to manage medicines, appropriately vet staff before they commence work and systems to reduce the risk of cross infection were not operated consistently. The practice must take urgent action to improve these aspects of the service. Although many aspects of the practice were good, improvement in both safety and leadership are required.

Our key findings were as follows:

  • the practice is involved in promoting health. It holds an award for smoking cessation.
  • patient feedback overall was very positive. Particularly in the areas of being treated with kindness and compassion and being involved in decisions about care and treatment.
  • a range of appointment options are available and additional appointments are made available at times of high demand.
  • the practice works closely with a very active patient focus group and acts on patient feedback.

We saw an area of outstanding practice:

  • arrangements were made with local commissioners to provide ear nose and throat, urology and ophthalmic clinics at the practice. Therefore, the need for patients to attend hospital outpatient clinics was reduced.

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

Importantly, the provider must:

  • ensure medicines are stored securely and a system is in place to check expiry dates of stored medicines.
  • act to improve standards of cleanliness and follow guidance to reduce the risk of cross infection.
  • carry out a risk assessment to determine the requirement for reception and administration staff to undergo criminal records checks.
  • carry out criminal records checks for practice nursing staff.
  • ensure all pre-employment checks are completed and recorded.
  • ensure there are recorded quality and monitoring  processes and procedures to identify, assess and manage risks to the safety and welfare of patients and others
  • risk assess portable electrical appliances and undertake appropriate safety checks based on findings.

In addition the provider should:

  • consider, with commissioners and local community groups, how a consistent and accessible translation service for patients whose first language is not English can be offered.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice