The Care Quality Commission
  • Doctor
  • GP practice

Bridgewater Surgeries

Overall: Good read more about inspection ratings

7 Printers Avenue, Watford, Hertfordshire, WD18 7QR (01923) 202600

Provided and run by:
Bridgewater Surgeries

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Bridgewater Surgeries on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Bridgewater Surgeries, you can give feedback on this service.

18 July 2022

During an inspection looking at part of the service

We carried out an announced inspection at Bridgewater Surgeries on 5 December 2019. The practice was rated as good overall; however, they were rated as requires improvement for providing well-led services.

The report for the December 2019 inspection can be found by selecting the ‘all reports’ link for Bridgewater Surgeries on our website at www.cqc.org.uk

This inspection carried out on 18 July 2022 was a desk-based review to confirm that the practice had made the necessary improvements in the areas we identified at our previous inspection in December 2019.

We based our judgement of the quality of care at this service on a combination of:

  • Information sent to us from the provider.
  • Information from our ongoing monitoring of data about services.

We rated the practice as good for providing well-led services because:

  • The practice had put an action plan in place to improve the systems and processes to ensure good governance.
  • The practice made use of an online platform to monitor practice activities. This included the ongoing monitoring of staff training, staff immunisation records and the professional registration of all clinical staff.
  • A new management structure was in place.

Additionally, where we previously told the practice they should make improvements our key findings were as follows:

  • There had been a decline in the uptake of childhood immunisations from the previous inspection in December 2019 when the practice met the minimum 90% uptake for four out of five childhood immunisations and exceeded the 95% World Health Organisation (WHO) target for one childhood immunisation. At this inspection the practice was below the minimum 90% target for three out of five of the childhood immunisations with all five below the WHO 95% target. The practice had an action plan in place to increase the uptake of childhood immunisations. For example,
    • The nursing staff telephoned parents or guardians of children due immunisations to book an appointment.
    • They telephoned the parents or guardians of children not brought in for immunisation appointments to discuss the benefits of immunisation and to book appointments. If there was no response to telephone calls, they would write to the parent or guardian.
    • A discussion regarding immunisations was held at the eight week baby check and the first immunisations were given at the same time if able.
    • they matched immunisation records for children registered from abroad to ensure medical records were complete.
  • The practice was below the 80% target set by the UK Health and Security Agency for cervical screening. However, there had been an increase since the previous inspection. For example, the percentage of persons eligible for cervical cancer screening at a given point in time who were screened adequately within a specified period had increased from 67% at the December 2019 inspection to 75% at this inspection. The practice had an action plan in place to increase the uptake of cervical screening. For example,
    • The practice sent reminder letters or text messages after the patient had been sent their initial invite letter.
    • Appointments for cervical screening were available early morning, evenings and on Saturdays.
    • Alerts were used on the patient clinical system to encourage clinicians to prompt patients that they were overdue cervical screening opportunistically if they had attended for another matter.
    • The practice planned to complete an audit of non-attenders to help them identify the reasons. This would include timings of appointments, disabilities, language barriers and cultural beliefs.

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

  • Continue to take actions to increase the uptake of childhood immunisations and cervical screening.

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

05/12/2019

During an inspection looking at part of the service

We decided to undertake an inspection of Bridgewater Surgeries on 5 December 2019 following our annual review of the information available to us. This inspection looked at the following key questions: Safe, Effective and Well Led.

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 organisation

We have rated this practice as Good overall.

We rated the practice Good for providing Safe and Effective services and rated all the population groups as Good.

We rated the practice as requires improvement for providing Well-Led services.

We rated the provider as requires improvement for being Well Led because:

  • Information systems lacked management overview as current systems were unable to provide coordinated assurance and performance data. For example, on staff training, staff immunisations, clinical staff professional registration.
  • Assurance and performance data had not been used effectively to adjust, improve performance or used to hold staff and management to account in some areas of practice activities. For example, those related to various HR activities, training and keeping staff information up to date.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • The practice organised and delivered services to meet patients’ needs.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care. However, the practice needed to introduce systems to continually monitor assurance and performance information to provide a management overview and to ensure sustained improvements.

We found the following areas where the provider must improve:

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

We found the provider should:

  • Continue to monitor the efficacy of the newly introduced system for periodic clinical staff registration checks.

  • Act to achieve the 95% WHO based target for childhood immunisations.

  • Act to achieve the cervical cancer screening 80% national programme coverage measure set by Public Health England.

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

4 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Coach House Surgery on 4 May 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective 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.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and 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 provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider should make improvement are:

  • Ensure that all staff complete a formal programme of infection control training relevant to their roles.
  • Ensure regular fire drills are completed at both premises on a regular basis.
  • Keep a record and analyse verbal complaints.
  • Monitor and assess systems and processes to ensure all aspects of practice management are in place and effective.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice