Bousfield Health Centre

Updated 21 November 2023

Bousfield Health Centre is located at Westminster Road, Liverpool, Merseyside, L4 4PP.

The provider Dr Don Jude Mahadanaarachchi is registered with CQC to deliver the regulated activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury.

Bousfield Health Centre is situated within the Cheshire and Merseyside Integrated Care System (ICs) and provides services to 3,100 patients under the terms of a general medical services (GMS) contract. This is part of a contract held with NHS England.

The provider operates nine GP practices across the Merseyside area. The practice is part of North Liverpool Primary Care Network, a wider network of GP practices.

There is a team of 3 locum GPs (1.2 whole time equivalents). They are supported by the whole time equivalent of 2.2 locum advanced nurse practitioners (ANPs), 1.2 whole time equivalent practice nurses, a part-time health care assistant and a part time pharmacist. 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 accessed via NHS111.

Information published by Public Health England shows that deprivation within the practice population group is in decile 1 (1 out of 10). The lower the decile, the more deprived the practice population is relative to others. A lower level of deprivation can indicate challenges in providing healthcare. The supply of healthcare services tends to be lower in more deprived areas due to a number of factors but has an increased demand. The population tends to have poorer health

status among individuals with a greater need for health services. Data available to us shows that the practice has a higher than average number of patients who have a long-standing health condition compared to the national averages. Fewer older and younger people are registered at the practice compared with others in Liverpool. More patients have diagnosed airways disease, depression, diabetes, high blood pressure and obesity compared with other practices in the area.

According to the latest available data, the ethnic make-up of the practice area is 94.7% White, 1.9% Asian, 1.5% Black, 1.2% Mixed, and 0.8% Other.

Updated 21 November 2023

We carried out an announced comprehensive inspection Bousfield Health Centre on 12 and 13 September 2023. Overall, the practice is rated as requires improvement.

Safe - Good

Effective – Requires improvement

Caring - Good

Responsive - Requires improvement

Well-led - Requires improvement

At the last inspection on 20 October 2021, the practice was rated requires improvement overall and for the key questions safe, responsive and well-led. The practice was rated as good for effective and caring services. We issued requirement notices in respect of breaches of Regulation 17 (Good governance) and Regulation 18 (Staffing) of the Health and Social Care Act (Regulated Activities) Regulations 2014.

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

At this inspection on 12 and 13 September 2023 we found that improvements had been made, but we identified areas that continue to require improvement.

Why we carried out this inspection

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

How we carried out the inspection/review

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 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 found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients mostly received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Changes had been introduced to improve patient access to the service and provide care and treatment in a more timely way. However, the impact of these changes was yet to be seen and further action was necessary.
• Information about how to make a complaint was not made readily available to patients and there was insufficient information to demonstrate that complaints had been appropriately investigated and responded to.
• Improvements had been made to the management and governance of the service but the impact and sustainability of some of the changes was yet to be demonstrated and some processes required further improvement.

We found the following breaches of regulation. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.

The provider should:

• Take action to provide information and guidance about the options for booking an appointment and the types of appointments available.
• Monitor the arrangements for patient access in terms of getting through to the practice by telephone and making an appointment.
• Continue to monitor and take action to improve the uptake for cervical cancer screening for eligible patients.
• Continue to monitor and take action to improve uptake for childhood immunisations.
• Take action to improve the system to review patients within one week of the prescribing of rescue steroids for patients with asthma.
• Take action to improve the recording of information for patients who have a DNACPR decision.
• Take steps to improve the availability of accessible information for patients.
• Take action to ensure emergency medicines are maintained securely at all times.

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