We carried out an announced comprehensive inspection at Bluebell Surgery on 5 March 2019 as part of our inspection programme.

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 and requires improvement for all population groups.

We rated the practice as requires improvement for providing safe services because:

• The practice did not have clear systems and processes to keep patients safeguarded from abuse. There was no clarity regarding who at the practice was the safeguarding lead.

• Health and safety, fire safety and safeguarding systems to manage risk were not in place or up to date.
• Appropriate standards of cleanliness and hygiene were being met. A lead for infection control had not been appointed and the annual audits and monitoring stated within their policy had not been carried out.

We rated the practice as requires improvement for providing effective services because:

• Patients received care and treatment that met their needs however, the practice had not audited the services they provided adequately, to be assured patient outcomes were improved.

We rated the practice as good for providing caring services because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• However, the practice had not formally identified patients that were carers to ensure they had access to the care and support they needed.

We rated the practice as good for providing responsive servicesbecause:

• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The practice listened to their patients and organised and delivered services to meet their patients’ needs.
• Patients could access care and treatment in a timely way.

We rated the practice as requires improvement for providing well-led services because:

• The practice lacked regular clinical oversight, to ensure care and treatment was well-led.

• The GP lead had the skills to deliver high-quality sustainable care however, did not have work time capacity for consistent oversight of all clinical and managerial work.

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:

• Improve the identification of carers to enable this group of patients access to the care and support they need.
• Improve the uptake of patients for the national cancer screening programme in particular, those in relation to breast and bowel screening.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care