The Care Quality Commission
  • Doctor
  • GP practice

Pound House Surgery

Overall: Good read more about inspection ratings

8 The Green, Wooburn Green, High Wycombe, Buckinghamshire, HP10 0EE (01628) 530997

Provided and run by:
Bourne End and Wooburn Green Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Pound 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 Pound House Surgery, you can give feedback on this service.

12 August 2021

During a routine inspection

We carried out an announced inspection at Pound House Surgery known locally Bourne End and Wooburn Green Medical Centre on 12 August 2021. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led – Good

Following our previous inspection on 28 October 2016, the practice was rated Good overall, with a rating of Requires improvement for Safe. We carried out a desk-top inspection to follow up on the key question of Safe, in December 2017, as we had found a breach of regulation in October 2016. This follow up review showed the practice had met the requirement we made in October 2016, and we then rated Safe as Good.

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

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on areas of concern raised with the Care Quality Commission (CQC).

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
  • Inviting staff to complete and submit a questionnaire to CQC
  • Requesting evidence from the provider
  • A short site visit to two of the practice’s three sites: Hawthornden Surgery and Pound House Surgery

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, Good for the five key questions and Good for all population groups.

We found that overall the practice was rated Good because:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. Although this included acting on safety alerts, the practice’s log of actions did not show whether further audits were carried out to ensure any changes required were embedded.
  • The practice had an appointed safeguarding lead who also contributed to in-house training. Staff understood their roles in relation to identifying and raising concerns relating to safeguarding. We found the policies for safeguarding children and safeguarding adults did not state the training levels required for staff, based on the Royal College of Nursing’s Intercollegiate guidance documents.
  • Patients received effective care and treatment that met their needs. Patient records were clearly and accurately completed. We found some areas where patients with long-term conditions did not receive all the monitoring tests recommended and this was an area the practice had already identified for further review and improvement.
  • 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. It had implemented new systems to help patients access care and treatment in a timely way. The practice was working with the commissioners to provide improved premises for delivering patient care.
  • There was a patient-centred ethos and staff worked as a team to make systematic improvements to the way the service was delivered. The practice had an active Patient Participation group with plans to increase patient involvement.
  • The practice leaders understood their key risks and had managed them over a period of significant change, whilst involving their staff and other stakeholders. New partners were being appointed to help with the leadership of the practice and the practice had recruited additional clinical and non-clinical staff. We found practice risks had been managed but had not been formally recorded. Records of meetings could be improved to help share information and decision-making.

The provider should:

  • Continue to act on safety alerts and log the actions taken, including any audits carried out to ensure actions are sustained.
  • Include the safeguarding training requirements in their safeguarding policies and continue to provide training to the required levels.
  • Continue to review the care of patients with long-term conditions to ensure they comply with National Institute of Health and Care Excellence guidance. In particular with respect to monitoring patients on specific medicines that might have adverse side-effects.
  • Continue to develop plans to manage the risks relating to the current premises.
  • Continue to develop ways to survey patients for their views about the practice.
  • Create minutes of meetings that are a clear representation of what was discussed and agreed so that those unable to attend are fully informed and involved.

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

We have not revisited the practice as part of this review because the practice was able to demonstrate that they were meeting the regulations associated with the Health and Social Care Act 2008 without the need for a visit.

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

At our previous comprehensive inspection at Pound House Surgery in Wooburn Green, Buckinghamshire on 28 October 2016 we found a breach of regulations relating to the provision of safe services. The overall rating for the practice was good. Specifically, the practice was rated requires improvement for the provision of safe services and good for the provision of effective, caring, responsive and well-led services. The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for Pound House Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 4 December 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection in October 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

We found the practice had made improvements since our last inspection. Using information provided by the practice we found the practice was now meeting the regulations that had previously been breached. We have amended the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective, caring, responsive and well-led services.

Our key findings were as follows:

  • We saw the practice had reviewed existing health and safety arrangements and environmental risks at both the main practice in Wooburn Green and the branch surgery in Bourne End. For example, gas safety checks and electrical installation checks had been undertaken and supporting correspondence recorded.
  • Revised recruitment policies and processes had been adopted which reflected national guidance. For example, supporting recruitment documentation (Disclosure and Baring Service checks) that was pending during the October 2016 inspection was now all recorded and documented correctly. The practice had also reviewed and amended the supporting policy which reflected updated guidance. Disclosure and Baring Service checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.
  • The practice had reviewed and updated the arrangements to record, share and action (where appropriate) medicine and other patient safety alerts. Specifically, practice had subscribed to receive alerts from Medicines and Healthcare Products Regulatory Agency.
  • Further steps had been taken steps to comprehensively track and monitor the security of all prescription stationary. This included a system to log the location of prescription stationary once transferred to the branch surgery.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

28 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the Pound House Surgery on 28 October 2016. Overall the practice is rated as good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Opportunities for learning from internal incidents were maximised.
  • Some risks to patients who used services were assessed and managed. However, not all reasonable steps were taken to assess and mitigate risks in relation to receiving and responding to patient safety alerts, Disclosure and Barring Checks, tracking and storing blank prescriptions, and maintenance and record keeping for the premises.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. However, not all staff had received training updates in a timely fashion.
  • Exception reporting rates were relatively high for heart failure and osteoporosis compared to CCG and national averages. The practice had taken a number of measures to try and reduce exception reporting rates.
  • 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 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.

We saw an area of outstanding practice:

  • The practice had developed a comprehensive strategy to further identify and improve outcomes for patients with dementia. The practice provided dementia screening, referrals to other services, and information about support organisations. The practice had conducted 335 dementia assessments since April 2016 and this resulted in 72 diagnoses of dementia. One GP and a member of reception staff were dementia champions and they had developed information packs for patients with dementia and their families. The practice had provided staff with training about dementia and identified and implemented measures to ensure the practice and environment were more dementia friendly. QOF figures for 2015 to 2016 showed that 94% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which is higher than the CCG average of 85% and national average of 84%.

The areas where the provider must make improvement are:

  • Complete required actions identified in the fire risk assessment, such as undertaking and documenting an electrical installation check for both premises.
  • Ensure that appropriate building checks and maintenance are undertaken and documented for both premises to include gas safety checks.

The areas where the provider should make improvement are:

  • Ensure staff receive DBS checks appropriate to their role or that appropriate assessments are undertaken to determine whether these are required and to identify and mitigate risks.
  • Ensure that there are adequate systems for receiving and actioning all patient safety alerts.
  • Embed systems to ensure that the location of all blank prescriptions is comprehensively tracked and that all blank prescriptions are stored securely.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice