Background to this inspection
Updated
6 July 2021
Dr Cyril Stephen (also known as Boyatt Wood Surgery) is located close to Eastleigh town centre in the residential area of Boyatt Wood:
Boyatt Wood Shopping Centre
Shakespeare Road
Eastleigh
Hampshire
SO50 4QP
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning, treatment of disease, disorder or injury and surgical procedures.
The practice is situated within the Hampshire, Southampton and Isle of Wight Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 7,800. This is part of a contract held with NHS England. The number of patients on the practice list has increased by almost 10% in the past two years.
The practice is part of a wider network of four GP practices, the Eastleigh Health Primary Care Network (the PCN), that work together to develop services for the local population. It has a close working relationship with two of the other three practices in the PCN with GP and management staff, in particular, working across sites.
The practice is in an area of low social deprivation. Its population has generally lower rates of long-standing health care conditions than the CCG and England average. The age distribution of the practice population shows a higher proportion of working age people and children, than the national average.
The practice has one GP partner and two salaried GPs. The practice also employs a practice manager, three practice nurses, a health care assistant and additional administration and reception staff. They have additional support from an advanced nurse practitioner, a locum GP and two practice nurses all of whom have provided regular sessions at the practice, particularly during the COVID-19 vaccination programme.
The practice telephone lines open between 8.00am until 6.30pm each day, with an earlier start of 7.30am on Tuesdays. Appointments are available from 8.30am until 6.30pm on Wednesdays, Thursdays and Fridays. The practice offers patients extended hours for pre-booked appointments every Monday between 6.30pm and 8pm and every Tuesday between 7.30am and 8.00am. When the practice is closed patients are directed to out of hours services by dialing the NHS111 service.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, there has been a growth in telephone consultations of over 100%. Although there had been a decrease in the number of face-to-face appointments, this continues to be a significant proportion of patient/doctor consultations.
Updated
6 July 2021
We carried out an announced inspection at Dr Cyril Stephen, also known as Boyatt Wood Surgery and visited the practice on 19 May 2021.
Overall, the practice is rated as Good.
The ratings for each key question are as follows:
Safe - Good
Effective - Good
Caring - Good (carried over from the previous inspection)
Responsive - Good (carried over from the previous inspection)
Well-led - Good
Following our previous inspection, published on 1 May 2019, the practice was rated Requires Improvement overall, with requires improvement ratings given for the two key questions Safe and Effective. We issued a requirement notice against Regulation 12 of the Health and Social Care Act Regulations 2014, Safe care and treatment. We judged there to be inconsistent safe management of medicines. The key questions of Caring, Responsive and Well Led were rated Good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Cyril Stephen on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a follow-up inspection, to follow up on the areas identified for improvement in the last inspection, including a breach of regulations and ‘shoulds’ identified in the last inspection. We inspected the three key questions, Safe, Effective and Well Led as part of our new methodology for inspecting services with a requires improvement rating.
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
- Requesting feedback from the patient participation group (PPG).
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 and Good for all population groups.
We found that:
- The practice had made changes and improvements in the areas we identified as requiring improvement at our last inspection. These included improvements in the care of the different population groups and the management of medicines
- 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.
- 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-centred care.
Whilst we found no breaches of regulations, the provider should:
- Continue to review and optimise prescribing levels for antibiotics, including the duration of the prescription.
- Document patient discussions in relation to risk factors associated with different medicines.
- Continue to log the actions taken in response to safety alerts and include the details of specific actions taken and by whom.
- Develop a more streamlined approach for creating and managing information internally, to support communication and the practice’s development within the wider PCN.
- Relaunch a quality improvement programme, disrupted by the practice’s COVID-19 response.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care