13 September 2023
During a routine inspection
We carried out an announced comprehensive inspection Bousfield Health Centre on 12 and 13 September 2023. Overall, the practice is rated as requires improvement.
Safe - Good
Effective – Requires improvement
Caring - Good
Responsive - Requires improvement
Well-led - Requires improvement
At the last inspection on 20 October 2021, the practice was rated requires improvement overall and for the key questions safe, responsive and well-led. The practice was rated as good for effective and caring services. We issued requirement notices in respect of breaches of Regulation 17 (Good governance) and Regulation 18 (Staffing) of the Health and Social Care Act (Regulated Activities) Regulations 2014.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bousfield Health Centre on our website at www.cqc.org.uk
At this inspection on 12 and 13 September 2023 we found that improvements had been made, but we identified areas that continue to require improvement.
Why we carried out this inspection
We carried out this inspection to follow up breaches of regulation from a previous inspection.
How we carried out the inspection/review
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A short site visit.
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 found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients mostly 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.
- Changes had been introduced to improve patient access to the service and provide care and treatment in a more timely way. However, the impact of these changes was yet to be seen and further action was necessary.
- Information about how to make a complaint was not made readily available to patients and there was insufficient information to demonstrate that complaints had been appropriately investigated and responded to.
- Improvements had been made to the management and governance of the service but the impact and sustainability of some of the changes was yet to be demonstrated and some processes required further improvement.
We found the following breaches of regulation. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
- Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
The provider should:
- Take action to provide information and guidance about the options for booking an appointment and the types of appointments available.
- Monitor the arrangements for patient access in terms of getting through to the practice by telephone and making an appointment.
- Continue to monitor and take action to improve the uptake for cervical cancer screening for eligible patients.
- Continue to monitor and take action to improve uptake for childhood immunisations.
- Take action to improve the system to review patients within one week of the prescribing of rescue steroids for patients with asthma.
- Take action to improve the recording of information for patients who have a DNACPR decision.
- Take steps to improve the availability of accessible information for patients.
- Take action to ensure emergency medicines are maintained securely at all times.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Health Care