Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection of this practice on 26 November 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us with an action plan to say what they would do to meet legal requirements in relation to Regulations:

• Regulation 15 HSCA 2008 (Regulated Activities) Regulations 2010 Safety and suitability of premises.

We undertook this focused inspection on the 12 July 2016 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements and issues identified in the previous report. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Bootle Village Surgery on our website at www.cqc.org.uk.

Overall the practice is rated as good.

Our key findings were:

The practice had addressed the breaches of regulations and other issues identified during the previous inspection and made improvements including:

• Risk assessments for health and safety had been carried out and action had been taken against the risks identified.
• Purchasing a defibrillator to manage medical emergencies at the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This is our report from an announced follow up comprehensive inspection at Bootle Village Surgery on 26 November 2015. We previously inspected this service on 4 November 2014. We rated the service as requires improvement for providing safe and well led services. We issued compliance actions (under the previous regulations) as a result of our findings and requested an action plan from the provider detailing how improvements would be made and when they would be compliant with the regulatory standards.

The provider is rated good overall. Although some improvements had been made, the provider is still rated as requires improvement for providing safe services. Our key findings were:

• The provider had met the compliance actions regarding satisfactory recruitment records and some aspects of governance. However, there was still a shortfall of adequate risk assessments in place and appropriate action with regards to the safety of the premises and equipment.

• The practice did analyse significant events and had safeguarding procedures in place.

• Information about services and how to complain was available. The practice sought patient views about improvements that could be made to the service and acted on feedback, but had struggled to form a patient participation group.
• As a result of analysing trends in complaints and patient feedback, the practice had improved telephone access and altered appointment systems to allow greater patient access.

• Staff worked well together as a team and all felt supported to carry out their roles.

However, importantly, the provider must:

• Carry out a more comprehensive fire risk assessment than is currently in place and take necessary actions including having an electrical safety certificate for the premises.

• Carry out other health and safety risk assessments and act on health and safety alerts. For example, for the control of substances hazardous to health (COSHH), display screen assessments, Legionella, disabled access and the need for a defibrillator.

There were improvements the provider should consider:-

• Revise the current procedure in place for managing information from incoming hospital letters to reduce delays in updating patient records.

• Carry out more full cycle clinical audits to demonstrate improvement in patient outcomes.

• Regularly include significant events for discussion at practice meetings with more detailed minutes to show actions taken.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This is the report from our inspection of Bootle Village Surgery which is registered with the Care Quality Commission to provide primary care services.

We undertook a planned, comprehensive inspection on the 4 November 2014 at Bootle Village Surgery. We reviewed information we held about the services including patients comments and spoke with GPs and staff.

Bootle Village Surgery is rated as requiring improvement for providing safe and well led services. However, we had not seen any evidence to show that this had impacted on patient’s welfare and therefore the practice has been rated good overall.

Our key findings were as follows:

• There were some systems in place to mitigate safety risks. The premises were clean and tidy. Systems were in place to ensure medication including vaccines were appropriately stored and in date.

• The practice was effective. Patients had their needs assessed in line with current guidance and the practice promoted health education to empower patients to live healthier lives.

• The practice was caring. Feedback from patients and observations throughout our inspection highlighted the staff were kind, caring and helpful.

• The practice was responsive and acted on patient complaints and feedback.

• The staff worked exceptionally well together as a team and had regular staff meetings.

However, there were also areas of the practice where the provider needs to make improvements. 

Importantly, the provider must:

• Ensure that all records for management of the regulated activities are comprehensive to underpin the informal governance systems already in place. In particular, the practice must review and update all policies and risk assessments for the practice and ensure staff are aware of procedures and can access all policies. (Regulation 20 Health & Social Care Act 2008 (Regulated Activities) Regulations 2010 Records)

• Ensure that records and checks pertaining to the employment of staff for the purposes of carrying out the regulated activity are updated to include any recruitment checks (or risk assessments as to why recruitment checks not carried out) and professional registration status. (Regulation 21 Health & Social Care Act 2008 (Regulated Activities) Regulations 2010 Requirements relating to workers)

The provider should:

• Make patients aware there is a chaperoning service available.
• Make patients aware there is a complaints policy available and update the policy to give patients the correct contact details for who they should contact if they are not happy with the outcome of their complaint.
• Consider other ways to gain patients’ feedback for example using a patient participation group.
• Should ensure the findings from audits are cascaded to the whole practice to improve patients’ outcomes.
• Make sure there is a child safeguarding procedure and policy available for all staff.
• Ensure all staff receive infection control training suitable for their role.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We reviewed the information available to us about Bootle Village Surgery on 6 June 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.