Archived: Bousfield Surgery

Updated 24 June 2019

Bousfield Surgery is located at Westminster Road, Liverpool, Merseyside, L4 4PP 

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, and treatment of disease, disorder or injury.

Bousfield Surgery is situated within Liverpool Clinical Commissioning Group (CCG) and provides services to 3,444 patients under the terms of a general medical services (GMS) contract. This is a contract between general practices and NHS England for delivering services to the local community.

The practice has two male GP partners one male regular GP locum who works at the practice, three practice nurses, administration and reception staff and a practice management team. The practice informally works with other practices within the CCG area.

There are higher than average number of patients who have a long-standing health condition compared to the national average for example, 65% compared to the national average of 51%. Eleven percent of patients were unemployed compared to the national average of 4%.

The National General Practice Profile states that 95% of the practice population is white British. Information published by Public Health England, rates the level of deprivation within the practice population group as one, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.

Updated 24 June 2019

We carried out an announced comprehensive inspection at Bousfield Surgery on 25 April 2019. The practice was registered with CQC on 12 February 2018 this was the first inspection of this provider. 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.

The overall rating for this practice was requires improvement due to concerns in providing safe and well-led services. However, the population groups were rated as good because patients were able to access timely and effective care and treatment.

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

• The systems for the management of medicines were not robust.
• The systems and processes in place to monitor and act on safeguarding concerns were not robust.
• The recruitment systems did not effectively check the qualifications and skills of locum clinicians.
• The systems in place to log and disseminate MHRA alerts and NICE guidance were not effective.

We rated the practice as requires improvement for providing well-led services because:

• The overall governance arrangements in place were limited and did not support an overview of the performance and safety of the service.

• The practice had not undertaken appropriate steps to ensure that staff not employed by the practice were legally allowed to have access to patient records.

We rated the practice as good for providing caring, effective and responsive services because:

• The practice reviewed the effectiveness and appropriateness of the care it provided.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs.
• Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Ensure the recruitment systems and processes are safe and effective.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure the safeguarding process, systems and practice protects patients from abuse.

(Please see the specific details on action required at the end of this report).

• The areas where the provider should make improvements are:

• Offer appropriate training for the infection control lead to support them in their extended role.
• Introduce a system to audit patient consent to check this is being appropriately sought and recorded.
• Introduce a comprehensive programme of quality improvement and use information about care and treatment to make improvements.
• Review the complaints procedure to ensure it accurately reflect up to date guidance and legislation.
• Introduce an appraisal system for the nursing team.
• Continue to review antibiotic prescribing at the practice.

Dr Rosie Benneyworth

BM BS BMedSci MRCGP Chief Inspector of Primary Medical Services and Integrated Care

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

Overall summary

Updated 24 June 2019

Updated 24 June 2019

Updated 24 June 2019

Updated 24 June 2019

Updated 24 June 2019

Updated 24 June 2019