Bousfield Surgery

Updated 4 September 2023

Bousfield Surgery is located in Liverpool at:

Westminster Road
Liverpool
L4 4PP

The provider is registered with CQC to deliver the Regulated Activities, diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury. The provider operates nine GP practices across the Merseyside area.

Bousfield Surgery is situated within the Cheshire and Merseyside Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of about 2680. This is part of a contract held with NHS England.

The practice is part of North Liverpool Primary Care Network, a wider network of GP practices. Information published by Public Health England shows that deprivation within the practice population group is in the lowest decile (one of 10). The lower the decile, the more deprived the practice population is relative to others. According to the latest available data, the ethnic make-up of the practice area is 94.8% White, 1.8% Asian, 1.3% Black, 1.3% Mixed, and 0.7% Other.

The age distribution of the practice population closely mirrors the local and national averages.

There is a team of 3 GPs (1 full-time and two who cover when the full-time GP/ANP are unavailable). They are supported by 2 part-time locum advanced nurse practitioners (ANP), 2 part-time practice nurses, a part-time health care assistant and a pharmacy technician. Several staff work across the providers locations, these include a safeguarding co-ordinator, immunisations nurse and a mental health support worker. There is a team of reception/administration staff, and a practice manager provides managerial oversight. A central governance teamwork works across all the providers practices.

The practice is open between 8am to 8pm on Monday and from 8am to 6.30pm Tuesday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is also provided locally by Primary Care 24 Limited, where late evening and weekend appointments are available. Out of hours services are provided by NHS111.

Updated 4 September 2023

We carried out an announced comprehensive inspection at Bousfield Surgery on 26 June and 5 July 2023. Overall, the practice is rated as requires improvement.

Safe - good

Effective - requires improvement

Caring - good

Responsive - requires improvement

Well-led - requires improvement

Following our previous inspection on 1, 2 and 3 November 2022, the practice was rated requires improvement overall, it was rated as inadequate for well-led and requires improvement for providing safe and responsive services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bousfield Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection.

This was a comprehensive inspection which covered all key questions, safe, effective, caring, responsive and well-led.

How we carried out the inspection

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 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:

• The practice had clear systems, practices, and processes to keep people safe and safeguarded from abuse.
• Some staff had not had the required training for their roles.
• Uptake of childhood immunisations and cervical screening were below national target rates.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way.
• Complaints were not acknowledged in a timely way and did not always document the learning identified.
• There had been improvements to the management of the practice.
• The provider had not formally recorded the challenges faced by the practice and how they are to be overcome as part of the strategy for promoting the vision and values of the practice.

We found one breach of regulations. The provider must:

• Ensure persons employed in the provision of the regulated activity receive the appropriate training to enable them to carry out the duties.

The provider should:

• Improve the management of significant events and complaints by providing appropriate training to the person responsible for the investigation and documentation of significant events and complaints.
• Take action to acknowledge complaints in accordance with the providers complaint policy and document any learning from complaints.
• Take action to improve the system to review patient medication on an annual basis and within one week of prescribing of rescue steroids for patients with asthma.
• Take action to improve cervical screening and childhood immunisation uptake.
• Take action to improve patients experience of being able to get through to the practice by telephone.
• Take steps to improve the availability of accessible and easy to read information.
• Take steps to formally record the challenges faced by the practice and how they are to be overcome as part of the strategy for promoting the vision and values of the practice.

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