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