The Care Quality Commission
  • Doctor
  • GP practice

Bousfield Surgery

Overall: Good read more about inspection ratings

Westminster Road, Liverpool, L4 4PP

Provided and run by:
Dr Don Jude Mahadanaarachchi

Important: The provider of this service changed. See old profile

All Inspections

During an assessment under our new approach

Date of Assessment: 10 and 11 February 2026

Bousfield Surgery is 1 of several practices managed by Dr Don Jude Mahadanaarachchi and delivers services from this location at Westminster Road, Liverpool, L4 4PP to 2,713 patients under a contract held with NHS England. The practice is registered with the Care Quality Commission under the Health and Social Care Act 2008 to provide the following regulated activities, diagnostic and screening procedures, midwifery and maternity services, and treatment of disease, disorder or injury. We carried out this assessment to follow up on breaches of regulation made at the last assessment of the service in July 2023. We assessed all the quality statements for the key questions of effective, responsive and well-led which had previously been rated requires improvement.

We carried out an announced on-site assessment on 11 February 2026. The National General Practice Profiles states that the demographics of the population are mainly White British with approximately 3.8% Asian, 3% Black, and 5% mixed or Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in decile 1 (1 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Since the last inspection the practice had made improvements and is no longer in breach of regulations. Systems were in place to improve uptake of national screening targets but despite this these remained lower than required. Complaints were now managed appropriately and the challenges faced by the practice were being formally managed. Where relevant, further commentary is provided in the quality statements section of this report.

26 June and 5 July 2023

During a routine inspection

We carried out an announced comprehensive inspection at Bousfield Surgery on 26 June and 5 July 2023. Overall, the practice is rated as requires improvement.

Safe - good

Effective - requires improvement

Caring - good

Responsive - requires improvement

Well-led - requires improvement

Following our previous inspection on 1, 2 and 3 November 2022, the practice was rated requires improvement overall, it was rated as inadequate for well-led and requires improvement for providing safe and responsive services.

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

Why we carried out this inspection

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

This was a comprehensive inspection which covered all key questions, safe, effective, caring, responsive and well-led.

How we carried out the inspection

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 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 have rated this practice as requires improvement overall.

We found that:

  • The practice had clear systems, practices, and processes to keep people safe and safeguarded from abuse.
  • Some staff had not had the required training for their roles.
  • Uptake of childhood immunisations and cervical screening were below national target rates.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • Complaints were not acknowledged in a timely way and did not always document the learning identified.
  • There had been improvements to the management of the practice.
  • The provider had not formally recorded the challenges faced by the practice and how they are to be overcome as part of the strategy for promoting the vision and values of the practice.

We found one breach of regulations. The provider must:

  • Ensure persons employed in the provision of the regulated activity receive the appropriate training to enable them to carry out the duties.

The provider should:

  • Improve the management of significant events and complaints by providing appropriate training to the person responsible for the investigation and documentation of significant events and complaints.
  • Take action to acknowledge complaints in accordance with the providers complaint policy and document any learning from complaints.
  • Take action to improve the system to review patient medication on an annual basis and within one week of prescribing of rescue steroids for patients with asthma.
  • Take action to improve cervical screening and childhood immunisation uptake.
  • Take action to improve patients experience of being able to get through to the practice by telephone.
  • Take steps to improve the availability of accessible and easy to read information.
  • Take steps to formally record the challenges faced by the practice and how they are to be overcome as part of the strategy for promoting the vision and values of the practice.

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

1, 2, 3 November 2022

During a routine inspection

We carried out an announced comprehensive at Bousfield Surgery on 1, 2 and 3 November 2022. Overall, the practice is rated as requires improvement.

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive – Requires improvement

Well-led – Inadequate

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. The practice has not been inspected since it was registered with the Commission on 26 March 2021.

How we carried out the inspection

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 rated this practice requires improvement overall.

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

  • Not all staff were trained to the appropriate levels of safeguarding for their role.
  • There were some shortfalls in the management of fire and health and safety at the practice.
  • The provider could not assure themselves that the premises were adequately cleaned.
  • The provider’s system to manage significant events was ineffective as not all staff were trained in the process and records of investigations undertaken were not kept.

We rated the practice as good for providing effective services. This is because:

  • Patients recived effective care and treatment that met their needs.


We rated the practice as good for providing caring services. This is because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice as requires improvement for providing responsive services. This is because:

  • Some patients reported difficulty in getting through to the practice by telephone.
  • The provider did not keep records of investigations into complaints and a track of actions arising from complaints.
  • Not all staff who dealt with and responded to complaints had received specific training.

We rated the practice as inadequate for providing well-led services. This is because:

  • The governance arrangements and their purpose were unclear, and there was a lack of clarity about authority to make decisions and how individuals are held to account. There was no process to review key items such as the strategy, values, objectives, plans or the governance framework.
  • The practice operational and governance structures were not clearly defined.
  • The systems for identifying, managing and mitigating some risks were ineffective.
  • The vision, values and strategy were not developed in collaboration with staff, patients and partners.

We found two breaches of regulations. The provider must:

  • Ensure all premises and equipment used by the service provider is fit for use.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

  • Continue to work to improve the uptake of cancer screening.
  • Take steps to make sure information is available in easy read formats.
  • Take action to improve patient’s experience of being able to get through to the practice by telephone.

The service has been rated as inadequate for being well-led and have six months to improve. We will inspect it again within six months. If the service is rated as inadequate for a key question at the second inspection, it will be placed in special measures.

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 Hospitals and Interim Chief Inspector of Primary Medical Services