The Care Quality Commission
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  • GP practice

Archived: Bilsthorpe Surgery

Overall: Good read more about inspection ratings

35 Mickledale Lane, Bilsthorpe, Newark, Nottinghamshire, NG22 8QB (01623) 870230

Provided and run by:
Dr Leah Robinson

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

All Inspections

30 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Bilsthorpe Surgery on 15 December 2015. A breach of legal requirements was found, in that not all improvements from the infection control audit dated November 2015 had been actioned.

Also, appropriate recruitment checks through the Disclosure and Barring Service (DBS) had not been undertaken for reception and administrative staff. The practice had not formally assessed the risk of employing the members of staff, including those who may undertake chaperone duties to determine whether a DBS check was required.

Overall the practice was rated as good; in view of the above the practice was rated as requires improvement for providing safe services.

After the comprehensive inspection, the practice wrote to us to say what action they had, and were taking to meet the legal requirement in relation to the breach. 

We undertook a desk based review on 30 August 2016 to check that the provider had completed the required actions, and now met the legal requirements. We did not visit the practice as part of this inspection. This report covers our findings in relation to the requirement.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Bilsthorpe Surgery on our website at www.cqc.org.uk.

Our finding across the areas we inspected was as follows:

  • The practice had taken appropriate action to meet the legal requirement.
  • The practice is rated as good for providing safe services.
  • The recruitment policy had been reviewed to ensure the practice obtained appropriate Disclosure and Barring Service (DBS) checks for all staff.
  • A DBS check was obtained for all reception and administrative staff following the comprehensive inspection. 
  • An action plan had been produced from the infection control audit dated November 2015, which showed that all areas requiring improvement had been completed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

15 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bilsthorpe Surgery on 15 December 2015. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • The practice had arrangements in place to deal with information about safety. Staff were aware of their responsibility to report incidents and concerns and knew how to do this. Information relating to safety was documented, monitored and reviewed
  • Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks and infection control.
  • Staff used best practice guidance to assess patients’ needs and plan their care. Staff had received relevant role specific training and further training needs were identified for staff through appraisal.
  • Patients told us staff treated them with compassion, dignity and respect and involved them in decisions about their care
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The practice had an active patient participation group (PPG) who worked with the practice to identify areas for improvement.

We saw one area of outstanding practice:

  • The practice offered a clinic for teenagers one afternoon per week. The clinic was timed to coincide with the school bus dropping off pupils outside of the practice. Patients were sent a letter by the practice in the month after they reached the age of 13 to advise them that the service was available. The practice told us 61 patients had been seen in the teenage clinic since 31 March 2015.

The areas where the provider must make improvements are:

  • Ensure recruitment arrangements include all necessary employment checks for all staff including checks with the Disclosure and Barring Service (DBS) or implement appropriate risk assessments where these checks are not in place.
  • Ensure a plan is in place to implement improvements identified as a result of infection control audits.

The areas where the provider should make improvements are:

  • Ensure all staff receive regular performance appraisals to ensure staff are supported in their roles and any training needs are identified.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice