The Care Quality Commission
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Archived: North Bicester Surgery

Overall: Requires improvement read more about inspection ratings

3 Barberry Place, Bure Park, Bicester, Oxfordshire, OX26 3HA (01869) 323600

Provided and run by:
North Bicester Surgery

All Inspections

5 May 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at North Bicester Surgery in August 2015. Breaches of the legal requirements were found relating to good governance. Following the comprehensive inspection, the practice wrote to us to tell us what they would do to meet the legal requirements in relation to these breaches.

We undertook this focussed inspection on 5 May 2016, to check that the practice had followed their plan and to confirm that they now met the legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for North Bicester Surgery on our website at www.cqc.org.uk.

We carried out a focussed follow up inspection of North Bicester Surgery on 5 May 2016 to ensure these changes had been implemented and that the service was meeting regulations. The ratings for the practice have been reviewed in relation to our findings.

At the inspection in May 2016, we found the practice had not made many improvements since our last inspection on August 2015 and were still in breach of the regulation relating to good governance.

Specifically the practice:

  • Carried out clinical audits in April and May 2016, but did not have an ongoing programme of audit.
  • Had not made sufficient changes to improve the feedback received from patients relating to appointments and waiting times.
  • Policies had been updated in April 2016 to reflect current legislation and guidance.
  • Were not effectively monitoring cleaning standards and were missing risk assessment information for cleaning products.
  • Had reviewed the complaints process to encourage development and learning, but did not share learning or outcomes with the whole practice or the PPG.
  • Did not hold regular PPG meetings to gather feedback or discuss current trends, despite this being a concern raised in August 2015.

We have considered and reviewed the ratings for this practice to reflect these findings. The practice is rated as requires improvement for the provision of effective and responsive care and inadequate for well led services.

The areas where the provider must make improvements are:

  • Ensure policies and procedures relating to the management of the service and health and safety are reviewed at intervals determined by a risk assessment of their relevance to the day to day running of the practice.

  • Ensure general cleaning standards are monitored effectively to confirm that appropriate cleaning standards are achieved.

  • Introduce a quality improvement plan, which includes the implementation of an audit plan and carry out completed audits that identify, assess and manage improvements in patient care in a timely manner. Implement and improve a system of operational audit cycles to ensure effective monitoring and assessment of the quality of the service.

  • Ensure effective and sustainable actions are taken to respond to patient feedback in regard to waiting times for appointments and accessibility to appointments.

  • Ensure learning from complaints are communicated consistently and effectively to all staff to reduce the risk of recurrence of similar events.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, it will be re-inspected within six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

26 August 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of North Bicester Surgery on 26 August 2015 under the new CQC comprehensive inspection approach. This was undertaken to look at the overall quality of the service, and to provide a rating for the service under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Overall the practice is rated as requiring improvement. Specifically it requires improvement for the delivery of effective, responsive and well led services. We have rated the practice as good for delivery of safe and caring services. Because we found the service requires improvement for effective, responsive and well led services all population groups are affected and have been rated as requiring improvement.

Our key findings were as follows:

  • The practice operated robust processes for managing medicines safely and the prescribing of medicines followed national guidelines and met prescribing targets.
  • Staff were appropriately trained to fulfil their role and received relevant support to discharge their daily duties.
  • The practice exceeded national targets for most child and adult immunisations and national screening programmes to support good health.
  • There were good working relationships with other providers of health and social care. Referrals to hospital services were made appropriately and efficiently.
  • Longer appointments were available for patients who were vulnerable or had complex care needs.
  • The practice achieved 98% of the national targets for care and review of patients with specific long term medical conditions in 2013/14.
  • There were visiting services available which enabled patients to be seen locally and not have to make the trip to hospital or other clinics. For example, sexual health clinic, talking therapies and private physiotherapy.
  • The practice did not review the quality of cleaning undertaken and some areas needed improvement.
  • Clinical audit to identify areas for improvement in patient care was limited.
  • The practice did not have an effective or sustainable approach to act upon patient feedback in regard to waiting times for appointments.

There are areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Ensure policies and procedures relating to the management of the service and health and safety are reviewed at intervals determined by a risk assessment of their relevance to the day to day running of the practice.
  • Ensure general cleaning standards are monitored effectively to confirm that appropriate cleaning standards are achieved.
  • Introduce a clinical audit plan and carry out completed audits that identify, assess and manage improvements in patient care in a timely manner.
  • Ensure effective and sustainable actions are taken to respond to patient feedback in regard to waiting times for appointments and accessibility to appointments.
  • Ensure learning from significant event and complaints reviews are communicated consistently and effectively to reduce the risk of recurrence of similar events.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

13, 24 January 2014

During a routine inspection

During our visits to North Bicester Surgery we met with the GP who was also the registered manager and with the practice manager. We spoke with five patients and with four members of staff.

Patients were offered options and involved in decisions about their care and treatment. One patient we spoke with said "I was given the option of medication or accupressure points' to manage discomfort. They chose to use accupressure and said they found this 'extremely helpful'.

Patients received treatment that was planned and delivered with regard to patient welfare. Patients with long term health conditions were followed up and invited for reviews of their care. A patient said "I get a reminder every February to get bloods and other tests taken".

The risk of patients contracting an infection had been reduced because appropriate guidance had been followed.

The risk from use of medicines was minimised because the provider had appropriate systems in place to manage medicines.

Staff received training relevant to their roles and responsibilities. Staff performance was not subject to review because supervision and appraisal processes were not effectively operated.

The provider did not have an effective system in place to seek and act on patient views, Patient satisfaction surveys had not been carried out.