Burvill House Surgery

Updated 26 August 2022

Burvill House Surgery is located in Hatfield, Hertfordshire. The practice is situated within the East & North Hertfordshire Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a population of approximately 12,036 patients living in Hatfield, Colney Heath, Smallford, Eastern St Albans, Welham Green, Bookmans Park and Southern Welwyn Garden City. This is part of a contract with NHS England. The practice operates from one site. The practice is part of a wider network of GP practice within the Hatfield Primary Care Network (PCN). The practice provides training to doctors studying to become GPs.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.

Information published by Public Health England shows that deprivation within the practice population group is in the seventh lowest decile (seven 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 76.4% White 12.2% Asian, 7.1% Black, 2.9% Mixed, and 1.4% Other.

The age distribution of the practice population closely mirrors the local and national averages. There are more working aged patients registered at the practice compared to local and national averages and a slightly lower older population.

There is a team of eight GPs who provide clinical services at the practice. There are five practice nurses including three nurse prescribers who provide nurse led clinics for long-term conditions. They are supported by a health care assistant. In addition, the practice employs a clinical pharmacist. A social prescriber and health and wellbeing coach provide additional services through the local PCN. The GPs are supported at the practice by a team of reception/administration staff. The practice manager and assistant practice manager provide managerial oversight.

The practice is open between 8.30 am to 6.30 pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

The practice offers extended opening on two evenings per week and alternate Saturday openings. When the service is closed patients can call NHS 111 for advice and treatment through a local out of hours service.

The practice operates from a two-story premises. Patient consultations and treatments take place on the ground floor. The first floor in mainly used by administrative staff. There is a car park outside the surgery.

Updated 26 August 2022

We carried out an announced inspection at Burvill House Surgery on 7 July 2022. Overall, the practice is rated as Good.

The key questions are rated as:

Safe - Good

Effective – Requires Improvement

Well-led - Good

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

Why we carried out this inspection

This inspection was a focused inspection. We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.

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 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 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 have rated this practice as Good overall

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients did not always receive effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

We found one breach of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

Whilst we found no breaches of regulations, the provider should:

• Embed identified improvements in medicines monitoring processes.
• Continue to ensure information is managed in line with current guidance and relevant legislation.
• Improve childhood immunisation uptake in line with national targets.
• Continue to improve cervical cancer screening uptake in line with national targets.
• Continue to develop a system to demonstrate the prescribing competence of non-medical prescribers.
• Improve patient access to appropriate health assessments and checks.
• Review the process of recording Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions in line with legislation and guidance.
• Embed and ensure staff understand the vision, values and strategy.
• Develop staff access to the Freedom to Speak Up Guardian for 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