The Burnham Surgery

Updated 14 September 2022

Burnham Surgery is located centrally in the village of Burnham on Crouch at:

Foundry Lane

Burnham On Crouch

CM0 8SJ

It is in close proximity to the train station and has parking available. The practice is in a privately-owned purpose-built building. The practice holds a General Medical Services (GMS) contract with NHS England. The GMS contract allows the practice to deliver primary care to the local communities. The practice has a list size of approximately 8,960 patients and provides GP services commissioned by Mid Essex Integrated Care Systems (ICS). An ICS is an organisation that brings together local GPs and experienced health professional to take on commissioning responsibility for local health services.

The practice is registered to provide the following regulated activities: diagnostic and screening procedures, family planning, maternity and midwifery and treatment of disease, disorder or injury.

The clinical team comprises three GP partners, and one GP. There are six nurses and three healthcare assistants. The clinical team are supported by a business manager and assistant practice manager and a team of receptionists and administration staff.

Appointments are available from 8am and 6:30pm Monday, Wednesday, Thursday and Friday and from 7am and 18:30pm on Tuesdays. Unscheduled out-of-hours and weekend care is provided by a local hub, a service set up by the Integrated Care Boards (ICB) and patients who contact the surgery outside of opening hours are provided with information on how to contact the service.

National data indicates that people living in the area are in the eighth most deprived decile of the deprivation scoring in comparison to England.

The practice has a comprehensive website providing information for patients to understand and access services, including useful contacts for specialist support services.

Updated 14 September 2022

We carried out an announced focused inspection at The Burnham Surgery on 17 August 2022. Overall, the practice is rated as good.

The ratings for each key question

Safe - Good

Effective - Good

Well-led – Good

The practice had previously been inspected in April 2021 under the previous provider. Since the previous inspection, the practice changed registration therefore continuing regulatory history applies to the practice.

The full reports for previous inspections under the previous provider can be found by selecting the ‘all reports’ link for The Burnham Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection focused on:

• Safe, effective and well-led services
• Areas followed up included any breaches of regulations or ‘shoulds’ identified in previous inspection

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

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.

We found that:

• The practice had systems in place to monitor and action safeguarding concerns. Although concerns were discussed with external agencies, the practice had not reviewed their patient information to ensure it was accurate.
• The practice had systems in place to monitor patients being prescribed high risk medicines in line with national guidance. We found patients were appropriately monitored.
• There was a system to review and act on safety alert. We found one example where appropriate action had not been taken. Since the inspection, the practice had reviewed and actioned the safety alert.
• Medicine reviews were carried out in line with national guidance and reviewed when required.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice was unable to demonstrate that staff had completed relevant mandatory training. Since the inspection, the practice had reviewed their training methods to ensure all staff had completed mandatory training.
• A range of emergency medicines were available at the practice however we found two of the recommended emergency medicines were not available. The practice had carried out an informal review however there was no documentation. Since the inspection, the practice had reviewed the emergency medicines held and provided a formal risk assessment.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

• Review safeguarding registers to ensure their accuracy.
• Strengthen systems to ensure safety alerts were actioned appropriately.
• Improve oversight of staff training.
• Review emergency medicines stored at the practice.
• Improve the uptake of cervical screening.

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