Bousfield Surgery

We carried out an announced comprehensive at Bousfield Surgery on 1, 2 and 3 November 2022. Overall, the practice is rated as requires improvement.

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive – Requires improvement

Well-led – Inadequate

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. The practice has not been inspected since it was registered with the Commission on 26 March 2021.

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.
• 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 and
• information from the provider, patients, the public and other organisations.

We rated this practice requires improvement overall.

We rated the practice as requires improvement for providing safe services. This is because:

• Not all staff were trained to the appropriate levels of safeguarding for their role.
• There were some shortfalls in the management of fire and health and safety at the practice.
• The provider could not assure themselves that the premises were adequately cleaned.
• The provider’s system to manage significant events was ineffective as not all staff were trained in the process and records of investigations undertaken were not kept.

We rated the practice as good for providing effective services. This is because:

• Patients recived effective care and treatment that met their needs.

We rated the practice as good for providing caring services. This is because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice as requires improvement for providing responsive services. This is because:

• Some patients reported difficulty in getting through to the practice by telephone.
• The provider did not keep records of investigations into complaints and a track of actions arising from complaints.
• Not all staff who dealt with and responded to complaints had received specific training.

We rated the practice as inadequate for providing well-led services. This is because:

• The governance arrangements and their purpose were unclear, and there was a lack of clarity about authority to make decisions and how individuals are held to account. There was no process to review key items such as the strategy, values, objectives, plans or the governance framework.
• The practice operational and governance structures were not clearly defined.
• The systems for identifying, managing and mitigating some risks were ineffective.
• The vision, values and strategy were not developed in collaboration with staff, patients and partners.

We found two breaches of regulations. The provider must:

• Ensure all premises and equipment used by the service provider is fit for use.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

• Continue to work to improve the uptake of cancer screening.
• Take steps to make sure information is available in easy read formats.
• Take action to improve patient’s experience of being able to get through to the practice by telephone.

The service has been rated as inadequate for being well-led and have six months to improve. We will inspect it again within six months. If the service is rated as inadequate for a key question at the second inspection, it will be placed in 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 Hospitals and Interim Chief Inspector of Primary Medical Services