Bluebell Lane Medical Practice

We carried out an announced assessment of Bluebell Medical Practice on 28 November 2023. The assessment focused on the responsive key question. This indicated that improvements were needed and as a consequence we carried out a comprehensive inspection on 17 and 22 January 2024. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - requires improvement

Caring - requires improvement

Responsive - inadequate

Well-led - requires improvement

Following our previous inspection on 17 April 2019 the practice was rated good overall and for all key questions. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bluebell Lane Medical Practice on our website at www.cqc.org.uk.

Why we carried out this review and inspection

We carried out the responsive assessment on 28 November 2023 as part of our work to understand how practices are working to try to meet demand for access and to better understand the experiences of people who use services and providers.

The responsive assessment focused on the responsive key question. This indicated that improvements were needed and as a consequence we carried out a comprehensive inspection on 17 and 22 January 2024.

How we carried out the review and the inspection

This responsive assessment on 28 November 2023 was carried out remotely. It did not include a site visit.

The process included:

• Conducting an interview with the provider and members of staff using video conferencing.
• Reviewing patient feedback from a range of sources.
• Requesting evidence from the provider.
• Reviewing data we hold about the service.
• Seeking information/feedback from relevant stakeholders.

This inspection on 17 and 22 January 2024 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 site visit.

Our findings

We based our judgement on a combination of:

• what we found when we met with the provider on 28 November 2023.
• What we found when we inspected on 17 and 22 January 2024.
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We found that:

• The systems in place for the management of long-term conditions had not consistently ensured patients had the required health monitoring.
• Records were not always appropriately completed, authorised and monitored to identify risks.

• Several staff had outstanding training that needed to be completed.
• The cervical screening rates for the practice were below the national target for cervical screening coverage.
• Childhood immunisation rates were below the World Health Organisation immunisation targets.

• Patient feedback was that they could not always access care and treatment in a timely way. Patients were dissatisfied with the arrangement for getting through to the practice by phone and their experience of obtaining an appointment.
• During the assessment process, the provider highlighted the efforts they were making or planning to make to improve the responsiveness of the service for their patient population. However, the patient voice about their experience of access to the practice and obtaining an appointment had been strong for some time and there was insufficient evidence that efforts made to date had improved patient experience.
• Complaints were not always managed appropriately.

We found a breach of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We also found, the provider should:

• Take action to hold records relating to the safety of the premises on-site.
• Take action to check emergency medication weekly as recommended by the Resuscitation Council UK guidelines and indicate in the risk assessment why recommended medicines are not held.
• Continue to monitor and improve cervical screening and childhood immunisation uptake.
• Take action to record the role specific induction provided to staff.
• Provide a summary of recorded meetings for staff unable to attend.

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