The Care Quality Commission
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  • GP practice

Evergreen Practice

Overall: Good read more about inspection ratings

Skimped Hill Lane, Bracknell, Berkshire, RG12 1LH (01344) 306936

Provided and run by:
Evergreen Practice

All Inspections

During an assessment under our new approach

Date of assessment: We carried out a focused assessment between 2 and 12 July 2024. Evergreen Practice is a NHS GP practice which provides primary care services to patients from one location in Bracknell, East Berkshire. We conducted this assessment to follow up our enforcement action from the last assessment where we found a single breach of regulation related to good governance. We assessed 5 quality statements across the key questions of safe and well-led and have combined the scores for these areas with the scores from the last assessment. The service is currently rated good overall and is now rated good for all the key questions: safe, effective, caring, responsive and well-led. At this assessment we found the service had made improvements and there were now clear governance arrangements between the practice and the Primary Care Network (PCN) related to staffing arrangements. Processes to manage medicines safety alerts from the Medicines and Healthcare products Agency were now effective. Processes to manage significant event activity (SEA) now ensured incidents were identified and learning was shared throughout the practice. Systems and processes to manage risks within the practice now provided clear information to management and risk was monitored. Systems and processes to support staff to speak up were clear and staff were confident about how to these. The service had a clear vision and strategy for the future focused on the needs of people and the community. Patients could request appointments in a way that met their needs and patients were able to access care and treatment in a timely manner.

During an assessment under our new approach

Evergreen Practice is a NHS GP practice which provides primary care services to patients from one location in Bracknell, East Berkshire. We carried out a focussed assessment between 22 January and 1 February 2024. We requested evidence from the practice, carried out remote interviews of staff and remote searches of the practices’ clinical system. The assessment also included a site visit. The assessment included 8 quality statements from 4 key questions which included safe, effective, responsive and well-led. The service is currently rated good overall and good for the following key questions: safe, effective, caring, and responsive. However, the key question of well-led is rated requires improvement. During our assessment we found the following: • Patients could request appointments in a way that met their needs, for example, online, telephone or face to face. • Patients were able to access care and treatment in a timely manner. • Vulnerable patients were prioritised for care and treatment. • We found no evidence of missed diagnosis for diabetes or chronic kidney disease stages 3, 4 or 5. • There was a lack of clear governance arrangements between the practice and the Primary Care Network (PCN) where PCN staff worked at the practice. • There was a lack of effective processes to manage medicines safety alerts from the Medicines and Healthcare products Agency. • Processes to manage significant event activity were not sufficiently embedded to ensure they were completely effective. • Systems to record and monitor risk did not include control measures to mitigate or reduce risks and opportunities to record risks had not been taken in all cases. During our assessment of this practice, we found concerns around governance processes within the practice which resulted in a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the key question findings below.

15 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

In October 2014 we fund concerns related to the recruitment of staff during a comprehensive inspection of Evergreen Practice. Following the inspection the practice sent us an action plan detailing how they would improve recruitment and undertake necessary staff checks. We carried out desktop review of the Evergreen Practice on 15 July 2015 to ensure these changes had been implemented and that the practice was meeting regulations. Our previous inspection in October 2014 had found breaches of regulations relating to the safe delivery of services. The ratings for the practice have been updated to reflect our findings.

We found the practice had made improvements since our last inspection on 2 October 2014 and they were meeting the regulation relating to the recruitment of staff that had previously been breached.

Specifically the practice was:

  • Operating safe systems in relation to the recruitment of staff.

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

02/10/2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Evergreen Practice is located in a large health centre in an urban area. It provides primary medical services to approximately 3500 registered patients.

We visited the practice location at Skimped Hill Health Centre, Skimped Hill Lane, Bracknell, Berkshire RG12 1LH  

We spoke with seven patients and eight staff during the inspection. This was the first inspection since registration. The announced, comprehensive inspection at Evergreen Practice took place on 2 October 2014.

Evergreen practice was rated as good overall.

Our key findings were as follows:

  • The practice is rated as requires improvement for safety. The practice had systems in place to report, investigate and respond to incidents and there was some  evidence to demonstrate shared learning across all practice staff relating to incidents and complaints. We found recruitment checks were not documented in accordance with the practice policies and current regulations.  We found the practice operated from clean, well maintained premises.
  • The practice is rated as good for effective. Patient outcome data was good. GPs treated patients in accordance with national and local guidelines.  Staff were trained and knowledgeable. The practice worked with other services to ensure patients with complex needs were cared for appropriately.
  • The practice is rated as good for caring. Feedback from patients and survey data showed the practice performed above the clinical commissioning group (CCG) and national average on patient satisfaction.
  • The practice is rated as good for responsive. there was an accessible complaints system with evidence demonstrating that the practice responded quickly to issues raised and shared learning across practice staff. Patients we spoke with and survey data demonstrated patients were very satisfied with access to the practice for urgent and routine appointments.
  • The practice is rated as good for well-led. The senior GP had a clear vision for the development of the practice and staff were confident in the leadership of the GP. The practice had an active patient participation group (PPG). Staff had received induction, regular performance reviews and were supported in their roles.

There was one area of practice where the provider needs to make improvements. 

Importantly, the provider must:

  • Ensure that all the recruitment checks are carried out and recorded as part of the staff recruitment process

In addition the provider should:

  • The practice should ensure governance arrangements are formalised including lines of management and accountability.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice