Background to this inspection
Updated
24 September 2021
Pound House Surgery is located in Wooburn Green in Buckinghamshire.
8 The Green
Wooburn Green
High Wycombe
Buckinghamshire
HP10 0EE
The practice has two branch surgeries at:
Hawthornden Surgery
Wharf Lane
Bourne End,
Buckinghamshire, SL8 5RX
The Orchard Surgery
Station Road
Bourne End
Buckinghamshire, SL8 5QE
The provider, Bourne End and Wooburn Green Medical Centre, is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning, treatment of disease, disorder or injury and surgical procedures.
Patients can access services at these three sites and staff work across all three.
The practice is situated within the Buckinghamshire Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of just over 14,000. This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices, the primary care network (PCN) known as Arc Bucks PCN. The PCN is made up of this practice and five others in the Beaconsfield and South West Chiltern areas.
Information published by Public Health England shows the practice population is amongst those with the lowest level of deprivation. It has a deprivation index level of 10 (in a range of 1-10) where the higher the decile, the least deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is 93% white, 3% Asian and 2% mixed. The practice population increased in size from 7,400 in July 2018 to 14,100 in August 2018, when two practices merged to form this single practice. This makes the practice larger than the CCG average of just under 12,000 patients and the England average of just over 9,000.
The age distribution of the practice population shows there are more people over the age of 55 than the England or CCG average, and a considerably fewer proportion of patients aged 20 to 40 years of age. There are more male patients registered at the practice compared with female patients.
The practice is staffed by a clinical team of 10 GPs and four nurses, supported by healthcare assistants, phlebotomists and a paramedic. The GPs are supported by a team of reception and administration staff. The practice manager is based at one of the branch sites, which forms the administrative hub.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face they are invited to one of the surgeries for their appointment.
Extended access is provided locally within the PCN, where late evening and weekend appointments are available.
Updated
24 September 2021
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