Archived: Bousfield Surgery

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