We carried out a review of the data available to us about Birdhurst Medical Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Birdhurst Medical Practice, you can give feedback on this service.
We carried out an announced comprehensive inspection at Birdhurst Medical Practice on 06 July 2021 as part of our inspection programme. In response to Covid- 19 we undertook a site visit on 09 July 2021 and carried out remote staff interviews prior to the site visit.
At our last inspection in January 2018 we found breaches of regulation and made a follow up inspection in December 2018 we rated the practice as Good overall.
During this inspection, we found that that uptake rates for childhood immunisations and cervical screening were low.
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.
Our findings
We have rated this practice as Good overall. We have rated effective as requires improvement due to two population groups; Families, children and young people
Working age people (including those recently retired and students) being rated as requires improvement.
We found that:
The provider should:
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
We carried out an announced focused inspection at Birdhurst Medical Practice on 12 December 2018.
At this inspection we followed up on breaches of regulations identified at a previous inspection on 11 January 2018.
We based our judgement of the quality of care at this service on a combination of:
We have rated this practice as good overall and good for all population groups.
We found that:
Whilst we found no breaches of regulations, the provider should:
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
This practice is rated as Good overall. The practice was previously inspected on 25 October 2016 and rated requires improvement overall.
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Requires improvement
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people with dementia) - Good
We carried out an announced comprehensive inspection at Birdhurst Medical Practice on 11 January 2018. The inspection was undertaken to follow up breaches of regulation identified at our previous comprehensive inspection undertaken on 25 October 2016. The practice was rated as requires improvement for key questions: Are Services Safe and Are services Well Led? Requirement notices were issued for regulation 12 and regulation 17 of the Health and Social Care act 2014 regulations as the practice did not have adequate systems and processes in place to ensure that risks associated with fire and infection control were mitigated, that action was being taken in response to patient safety alerts, that adequate recruitment checks had been completed for all staff and that all staff had completed recommended training.
At this inspection we found:
In most respects the practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. There was a minor risk associated with legionella where the practice had not taken action to ensure that this had been mitigated consistently.
Care and treatment was delivered according to evidence- based guidelines. The practice routinely reviewed the effectiveness and appropriateness of the care it provided. However there was limited evidence of work which aimed to improve the quality of care provided to patients and evidence suggested that coding of patient on the practice’s clinical system could be improved.
Staff involved and treated patients with compassion, kindness, dignity and respect.
Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
Governance systems were not effective in some areas for instance formalised clinical meetings where clinical updates alerts and guidance were discussed were infrequent and significant event and complaints were not routinely discussed in practice meetings. There were some gaps in essential training for staff. Evidence of comprehensive checks for locum staff were not present for a locum GP whose file we reviewed. The lack of quality improvement work, inconsistencies around coding and failure to consistently take action to mitigate risks associated with legionella also indicated deficiencies in governance.
The areas where the provider must make improvements are:
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The areas where the provider should make improvements are:
Increase frequency of formalised clinical meetings
Consider formalising the system for communicating learning outcomes from significant events and complaints.
Consider ways to improve the uptake of childhood immunisations.
Consider ways to improve the identification of patients with caring responsibilities and offer appropriate support to these patients.
Improve advertising of bereavement services.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Birdhurst Medical Practice on 25 October 2016. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
The areas where the provider must make improvement are:
Ensure that there are systems in place for ensuring that action is taken in response to patient safety alerts and that this is recorded.
Ensure that there are appropriate systems in place to mitigate against risks associated with fire and infection control.
Ensure that all staff have received appropriate essential training.
Ensure that effective systems are in place in respect of medicine management including monitoring systems for controlled drugs and prescription pads. Ensure that recruitment and monitoring procedures are effective.
The areas where the provider should make improvement are:
Continue to work on developing mechanisms to gather feedback from patients.
Put systems in place to improve the identification of and support offered to patients who act as carers or those who have suffered bereavement.
Review methods used to advertise chaperoning and translation services.
Review areas where exception reporting rates are higher than local and national averages to ensure that these are appropriate and take action if required to reduce the number patients exception reported.
Review complaints procedures and policies to ensure that they comply with current legislation and guidance and consider the appropriateness of responses.
Consider introducing formal business or strategic planning.
Review failsafe mechanisms in place for monitoring the temperature of vaccines.
Consider offering longer appointments for patients with learning disabilities or complex conditions.
Review patients to ensure that all those with Chronic Obstructive Pulmonary Disease are being identified.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
It was evident from records we examined and feedback we received from patients and their representatives that they felt their privacy and dignity was respected by staff at the practice and were involved in discussions about their treatment options. We found patients received safe and appropriate treatment and support from suitably trained and experienced doctors, nurses and non-clinical staff (i.e.receptionists). The practice was kept hygienically clean and they had effective systems in place to routinely monitor and review the standard of care and treatment patients received. We also found patients had their comments and complaints listened too.