The Care Quality Commission
  • Doctor
  • GP practice

Burvill House Surgery

Overall: Good read more about inspection ratings

52-54 Dellfield Road, Hatfield, Hertfordshire, AL10 8HP (01707) 269091

Provided and run by:
Burvill House Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Burvill House Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Burvill House Surgery, you can give feedback on this service.

07 July 2022

During an inspection looking at part of the service

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

3 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Burvill House Surgery 0n 3 March 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.

  • The practice offered a daily triage service by a duty GP which enabled them to direct patients to the most appropriate member of the healthcare team for their care and treatment. This system allowed the practice to manage the volume of patients seeking appointments most effectively and safely on a daily basis.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvements are:

  • Commission the recently acquired defibrillator.

  • Continue to monitor the changes made to the appointment system to ensure patients access to services is improved.

  • Continue to engage its patients so a Patient Participation Group is active in the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

26 February 2014

During a routine inspection

During our inspection we spoke with eight patients face to face and one by phone. We spoke with six members of staff.

When patients received care or treatment they were asked for their consent and their wishes were listened to. One patient told us: "Yes I give consent because they have explained why". We found that when minor surgery had been carried out written consent had been requested from patients before the surgery had commenced.

We saw that patients' views and experiences were taken into account in the way the service was provided. The patients we spoke with said they were satisfied with their care. A patient told us: "The doctors are amazing. I couldn't fault any of them". Patients received their medicines when they needed them.

Staff had received training in safeguarding children and vulnerable adults. They were aware of the appropriate agencies to refer safeguarding concerns to. This ensured that patients were protected from harm.

We found that staff had received appropriate training for the roles they carried out. They were also monitored by their line manager and had regular appraisals. This indicated staff had been appropriately assessed regarding their competency.

The provider had a system in place for monitoring the quality of service provision. They regularly obtained opinions from patients about the standards of the services they received. This meant that on-going improvements could be made by practice staff.