Bousfield Health Centre

We carried out an announced inspection at Bousfield Health Centre on 20, 21 October 2021 and

3 November 2021. Overall, the practice is rated as Requires Improvement.

The ratings for each key question are as follows:

Safe - Requires Improvement

Effective – Good

Caring – Good

Responsive – Requires Improvement

Well-led - Requires Improvement

We carried out an inspection at Bousfield Health Centre in April 2019 under the previous provider of services. At this time, the practice was rated requires improvement overall and for being safe, responsive and well-led and good for being effective and caring. We issued requirement notices in respect of breaches of Regulation 12 (safe care and treatment), Regulation 13 (safeguarding) and Regulation 17 (good governance) of the Health and Social Care Act (Regulated Activities) Regulations 2014.

The new provider, Dr Don Jude Mahadanaarachchi, took over this location in March 2021. The provider has another eight locations registered with the Commission under this registration. The provider also has other separate provider registrations with the Commission and was responsible for 14 GP practices in total.

At this inspection on 20 and 21 October 2021 and 3 November 2021 we found that some required improvements had been made, and identified other areas that required improvement.

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 carried out on 20, 21 October 2021 and 3 November 202 we inspected the key questions safe, effective, caring, responsive and well-led.

Why we carried out this inspection

This inspection was to follow up on the previous breaches of regulation and to allow us to change the rating of the practice if appropriate.

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/reviews 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 practice 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 have rated this practice as Requires Improvement overall.

We found that:

• Since the last inspection the practice had been redecorated and some improvements to the building were made.
• Effective measures were put in place to minimise the risk presented by the Covid-19 pandemic.
• The process for the monitoring patients’ health in relation to the use of medicines including high risk medicines had improved.
• Patients’ needs were assessed, and care and treatment were delivered in line with current legislation, standards and evidence-based guidance, supported by clear pathways and tools.
• Staff had the information they needed to deliver safe care and treatment.
• Staff treated patients with kindness, respect and compassion.

The practice is rated as requires improvement for providing safe services because;

• GP’s and practice staff were not trained in safeguarding matters to appropriate levels for their role.
• Recruitment checks were partially carried out in accordance with regulations.
• The practice could not effectively demonstrate the prescribing competence of non-medical prescribers.
• There was limited evidence of learning and dissemination of information for the management of significant events.

The practice is rated as requires improvement for providing responsive services because;

• Significant concerns were raised about the practice telephone system cutting people off and being on hold for a long period of time. A solution to improve the system was being sought.
• The issues with the telephone system resulted in people raising concerns about not being able to book appointments and access treatments and services in a timely way.
• There was insufficient evidence that complaints were used to drive continuous improvement.

The practice as requires improvement for providing well led services because;

• The provider used a high number of locum staff to maintain clinical staffing levels without effective oversight of their recruitment, training and appraisal. We found that locum staff could operate at the practice without any written agreement or contract in place.
• There were staff members who had not completed the required training to deliver effective services safely. Some staff did not have access to regular appraisals and supervision.
• Clinical and staff meetings had lapsed, and locum staff did not have the time to attend clinical meetings scheduled into their working day.
• The practice did not have a Patient Participation Group and there had been no recent patient survey completed.

The practice was rated as good for providing caring services.

We found two breaches of regulations. The provider must:

• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
• Establish effective processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

• Review how patient views are acted on to improve services and culture.
• Review the different types of patient consultations and appointments available to ensure those whose circumstances may make them vulnerable or who have a continuing condition to ensure they are reviewed in a timely manner by the most appropriate clinician.
• Continue to monitor and take actions to improve the uptake for cervical cancer screening for women at the practice.

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