Archived: Bilsthorpe Surgery

We carried out an announced inspection Bilsthorpe Surgery on 8 June 2022. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 30 August 2016 the practice was rated Good overall and for all key questions.

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

Why we carried out this inspection

This was a comprehensive inspection as this location had been registered by CQC following a change in service provider.

How we carried out the inspection/review

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
• Conducting interview with key stakeholder using video conferencing
• Interview with patients

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
• information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall

We found that:

• 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 adjusted how it had delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• The culture of the practice and the way it was led and managed drove the delivery and improvement of high-quality, person-centred care.
• All opportunities for learning from internal and external incidents were maximised. All learning was shared with staff and external organisations regularly.
• Leaders demonstrated they had the capacity and skills to deliver high quality, sustainable care and understood the challenges facing the practice.
• There was emphasis on staff wellbeing, and this was demonstrated through discussions with staff and evidence of appraisals. Staff were encouraged to develop and were provided with training opportunities.
• Risk management processes were in place and we found assessments of risks had been completed. These included fire safety, health and safety, and infection control. This ensured that risks had been considered to ensure the safety of staff and patients and to mitigate any future risks.

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

• Implement formal review of prescribing and consultations carried out by staff employed in advanced clinical practice.
• Update and maintain the practice website to include appropriate support and information to patients.

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