Bounds Green Group Practice

We carried out an announced comprehensive inspection at Bounds Green Group Practice (the practice) on 26 September 2019 as part of our inspection programme. We rated the practice as Good overall and in respect of the key questions Effective, Caring, Responsive and Well-led and for the six population groups. We rated it as Requires improvement for providing Safe services, because of concerns with infection prevention and control processes and management of emergency medicines and equipment. We served a requirement notice under regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, relating to Safe care and treatment.

We also stated that the practice should make improvements in the following areas:

• Consider introducing a system to record and monitor actions taken as a result of patient safety alerts, including a step to ensure these are read and acknowledged by relevant staff.
• Put steps in place to ensure clinical equipment carried in doctors bags undergoes calibration testing in line with guidance

Our report of the September 2019 inspection can be found by going to the following page of our website and selecting the Reports tab: https://www.cqc.org.uk/location/1-564499987

After the inspection, the practice sent us a plan of actions it intended to take to ensure it was able to meet the legal requirements under the key question, Safe.

This focussed inspection was carried out 24 September 2020 as a desk-based review of evidence provided by the practice, looking at the issues previously identified to check and confirm that the practice had carried out its plan to meet the legal requirements. It included an online meeting between our inspector and practice staff.

We found that the practice had taken appropriate action to meet the requirements of the regulations relating to providing a Safe service. Accordingly, we have revised the practice’s rating in respect of providing Safe services to Good. The revised rating has not changed the overall rating for the practice, which remains Good.

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 carried out an announced comprehensive inspection at Bounds Green Group practice on 26 September 2019 as part of our inspection programme.

We decided to undertake an inspection of this service following our annual review of the information available to us.

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 and for all population groups.

We rated the practice as requires improvement for providing safe services because:

We found that:

• The practice had not taken sufficient action to ensure concerns identified in the most recent infection prevention and control audit were managed consistently and it did not have an effective process in place to identify other concerns as they emerged.
• The system used to manage clinical specimens did not keep people safe from harm because containers used to collect specimens could be accessed by the public, including children.
• The practice was equipped to deal with medical emergencies but there were gaps in the monitoring of emergency equipment. Specifically, a room used for administering flu vaccines did not have an anaphylactic kit available, a first aid box did not contain all the items listed and a resuscitation kit contained one phial of adrenaline which had exceeded the expiry date by three months.
• The practice had not taken steps to avoid a fridge used to store vaccines being switched off accidentally.

We rated the practice as good for providing effective, caring, responsive and well led services because:

We found that:

• The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care. Patient feedback was consistently positive. This included the results of the national GP survey, CQC comment cards and patient interviews.
• Overall, patients could access care and treatment in a timely way. Some patients reported that access to appointments was difficult, the practice was taking action to address this
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Consider introducing a system to record and monitor actions taken as a result of patient safety alerts, including a step to ensure these are read and acknowledged by relevant staff.
• Put steps in place to ensure clinical equipment carried in doctors bags undergoes calibration testing in line with guidance.

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