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Review carried out on 30 May 2019

During an annual regulatory review

We reviewed the information available to us about Blundellsands Surgery on 30 May 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 20 July 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at this practice on 12 November 2015.

A breach of legal requirements was found. The practice was required to make improvements in the domain of ‘Safe’.

After the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Safeguarding service users from abuse.

We undertook this focused follow-up review to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Blundellsands Surgery on our website at

Our key findings were as follows:

  • The practice had addressed the issues identified during the previous inspection.

  • Improved systems were in place to ensure that all requests for child safeguarding reports were being met.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 12 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Blundellsands Surgery on 12 November 2015. Overall the practice is rated as Good .

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.

  • Safeguarding systems were in place and staff demonstrated their understanding of these. However, we found that requests for safeguarding reports were not always met.

  • The practice reviewed data to improve performance, but where unable to provide examples of completed audit cycles.

  • The practice used proactive methods to improve patient outcomes, working with other local providers to share best practice.

  • Feedback from patients about their care was consistently and strongly positive.

  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet people’s needs.

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand
  • The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider must:

  • Ensure all requests for safeguarding reports are met, and that reports are submitted to safeguarding review boards in the required format.

Additionally, there are areas where the practice should make improvements.

The practice should

  • Ensure that audits started are completed and meet the clear definition of the clinical audit cycle.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice