The Care Quality Commission
  • Doctor
  • GP practice

Burnett Edgar Medical Centre

Overall: Good read more about inspection ratings

Central Drive, Walney Island, Barrow In Furness, Cumbria, LA14 3HY (01229) 474526

Provided and run by:
Burnett Edgar Medical Centre

All Inspections

During an assessment under our new approach

Date of Assessment: 15 October 2026. Burnett Edgar Medical Centre is a GP practice and delivers services to approximately 4076 people under a contract held with NHS England. According to the latest available data, the ethnic make-up of the service area is approximately 97.8% White, 0.9% Asian, 0.7% Mixed, 0.3% Black and 0.2% Other. Information published by the Office for Health Improvement and Disparities shows deprivation within the service population group is in the 5th decile (5 of 10). The lower the decile, the more deprived the service population is relative to others.

This was a focused assessment. We undertook this assessment due to the length of time since our last assessment. We assessed 10 quality statements from across all 5 key questions. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

SAFE: Staff kept facilities clean and maintained equipment appropriately to ensure people were kept safe. They assessed and managed the risk of infection well and took steps to control the risk of it spreading. There were enough staff with the right skills, qualifications and experience.

EFFECTIVE: Staff supported people to live healthier lives, monitoring their care and treatment to ensure they received positive and consistent outcomes. Staff supported national priorities and initiatives to improve patient health.

CARING: Staff treated people with kindness, empathy and compassion, and respected their privacy and dignity.

RESPONSIVE: People could access care, treatment and support when they needed it. Leaders and staff were alert to discrimination and inequality that could disadvantage groups of people who used the service and sought ways to address any barriers.

WELL-LED: The service had a clear vision and strategy, which considered the needs of the people who used their service and the wider community. Staff understood their individual roles and responsibilities. Leaders accounted for the actions, behaviours and performance of staff through clear and effective governance processes.
 

17 January 2020

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Burnett Edgar Medical Centre on 16 November 2018 as part of our inspection programme. We rated the practice as requires improvement for providing safe services and good overall.

The full comprehensive report on the November 2018 inspection can be found by selecting the ‘all reports’ link for Burnett Edgar Medical Centre on our website at www.cqc.org.uk.

At our inspection in November 2018 we rated the practice as requires improvement for providing safe services because:

  • Records of staff training were incomplete, and some staff had not undertaken training according to practice policy.
  • The practice clinical audit programme was in need of review to ensure it was appropriate for the needs of the practice.

We also indicated improvements should be made as follows:

  • Perform an analysis of themes from significant events to look for trends;
  • Include details of safeguarding procedures in the locum pack.

On 17 January 2020, we carried out a focused, desk-based inspection of the safe key question. We reviewed evidence submitted by the practice to confirm it had carried out the plan to meet the legal requirements in relation to the breaches in regulations identified in our previous inspection on 16 November 2018. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At this inspection, we found that the provider had satisfactorily addressed all legal requirements and suggestions for improvements.

We have rated this practice as good for providing safe services.

We found that:

  • Adherence to practice policy and procedure in relation to staff training was improved. Staff and GPs had generally undertaken required annual training and there were comprehensive records of this in place.
  • We saw evidence staff were appropriately trained for safeguarding patients and safeguarding information had been included in the GP locum pack.
  • There was evidence of an audit programme appropriate to the needs of the practice.
  • The management of significant events had improved, and we saw learning was shared routinely with staff.

Whilst we found no breaches of regulations, the provider should:

  • Ensure all staff and GPs follow the practice protocol for undertaking annual practice mandatory training in all areas, including fire training.

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

16 Nov 2018

During a routine inspection

This practice is rated as Good overall. (Previous rating November 2015 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Burnett Edgar Medical Centre on 16 November 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a focus on continuous learning and improvement at all levels of the organisation.

We saw an area of outstanding practice:

  • Doctors at the practice worked closely with the Integrated Care Community (ICC) to set up a community-based support group for patients with neurological conditions called Café Neuro, and a Wellness Group which used yoga, healthy eating advice, and relaxation techniques involving Virtual Reality headsets to encourage patients to lower stress levels and improve their overall wellbeing.

However, we saw some areas where the practice must make improvements:

  • Ensure systems and processes are operated effectively For details, please refer to the requirement notice at the end of the report.

We also saw some areas where the practice should make improvements:

  • Perform an analysis of themes from significant events to look for trends;
  • Include details of safeguarding procedures in the locum pack.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

3 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Burnett Edgar Medical Centre on 3 November 2015. Overall the practice is rated as good.

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

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Information about services and how to complain was available and easy to understand.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff told us they felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

We saw some areas of outstanding practice:

  • The practice was rated as outstanding for providing responsive services. The practice worked with other services and the local community to provide services which benefitted people’s needs. For example, the GP partners allowed local community groups and services to use a building adjoining the surgery free of charge to provide activities for carers and for people with dementia, as well as hosting foot care, disability advice, a community pharmacy and dietary support.

  • One of the GP partners had created an evidence-based online forum called Patient Memoirs to help patients, carers and professionals. It used video clips of patients talking about their experiences to support other patients and help them cope emotionally with their conditions. For example, staff told us of a diabetic patient who was afraid of injections who was able to administer their own insulin safely after using the site for support.

However, there were some areas where the provider should make improvement:

  • Ensure staff are given annual appraisals.

  • Consider how to improve the privacy for patients in some consultation rooms.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice