The Care Quality Commission
  • Doctor
  • GP practice

Bird-In-Eye Surgery

Overall: Good read more about inspection ratings

Uckfield Community Hospital, Framfield Road, Uckfield, East Sussex, TN22 5AW (01825) 763196

Provided and run by:
Bird-In-Eye Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Bird-In-Eye Surgery 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 Bird-In-Eye Surgery, you can give feedback on this service.

25 June 2021

During an inspection looking at part of the service

We carried out an announced desktop review at Bird-in-Eye surgery on 25 June 2021. Overall, the practice is rated as Good.

Safe - Good

Following our previous inspection on 12 February 2020, the practice was rated Good overall for providing effective, responsive, caring and well-led services but requires improvement for providing safe services. We identified breaches of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and issued a requirement notice.

We carried out this inspection of Bird-In-Eye surgery to confirm that the service now met the legal requirements in relation to those breaches of regulation and to ensure sufficient improvements had been made. As a result of this inspection, the service is now rated as good for providing safe services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bird-in-Eye surgery on our website at www.cqc.org.uk

How we carried out the review

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our reviews differently.

This review was carried out in a way which enabled us to spend no time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Requesting evidence from the provider
  • Reviewing supplied evidence to verify that it met the standards required under regulations
  • Speaking with staff using video conferencing

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 Good overall and good for all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • The practice acted accordingly on safety alerts received within practice and ensured these were disseminated to appropriate staff.
  • The practice assured themselves that only fit and proper people worked within the practice and undertook appropriate checks to ensure this.

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

12 February 2020

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Bird-in-Eye Surgery on 12 February 2020 as part of our inspection programme.

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions:

  • Effective
  • Well-led

As a result of information reviewed at the time of inspection we also looked at the following key question:

  • Safe

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 good overall and for the key questions with the exception of safe which was rated as requires improvement. We rated them as good for all the population groups.

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

  • Safety alerts were not sufficiently recorded to provide evidence that these were appropriately acted on.
  • Evidence of satisfactory conduct in a previous role was not recorded as part of the recruitment checks for locum GPs.

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

  • The practice had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance.

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

  • There was a clear leadership structure and staff felt supported by management.

The areas where the provider must make improvements are:

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

The provider should:

  • Continue work to increase the uptake of cervical screening.
  • Review mental health exception reporting with a view to reducing this.

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

24 June 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 of this practice on 1 December 2015. Breaches of Regulatory requirements were found during that inspection within the effective and well led domains. After the comprehensive inspection, the practice sent us an action plan detailing what they would do to meet the regulatory responsibilities in relation to the following:

  • To ensure that staff undertook an appraisal process that was commensurate with their role.
  • To review that meetings within the practice were minuted adequately to assist in the good governance of the practice.
  • To review the progress that the practice had made in having an active patient participation group (PPG) in place so the practice could be more responsive to the needs of their patient list.

We undertook this focused inspection on 24 June 2016 to check that the provider had followed their action plan and to confirm that they now met regulatory 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 Bird-in-Eye Surgery on our website at www.cqc.org.uk.

This report should be read in conjunction with the last report published in February 2016. Our key findings across the areas we inspected were as follows:-

  • We saw that there was a robust system in place to ensure staff undertook an appraisal and that this meeting detailed objectives for the staff member and documented any training requirements.
  • We saw evidence that meetings were being minuted to show a record of what was discussed and any actions documented that were subsequently required to be undertaken.
  • We met with a member of the PPG to discuss the progress of the group and saw evidence of recent meetings.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

01 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bird-in-Eye Surgery on 1 December 2015. Overall the practice is rated as requires improvement.

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.
  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.

  • 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.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • The practice had good facilities and was well equipped to treat patients and meet their needs

  • Patients said they could make an appointment with a named GP and that there was continuity of care, with urgent appointments available on the same day.

  • Urgent appointments were usually available on the day they were requested.
  • The provider was aware of, and complied with, the requirements of Duty of Candour.
  • The practice worked closely with other organisations in planning how services were provided to ensure that they met people’s needs.

The areas where the provider must make improvements are:

  • To ensure staff appraisals are undertaken.

  • To establish a Patient Participation Group (PPG).

  • To record minutes of meetings to assist in effective governance.

In addition the provider should:

  •  Review the changes to the telephone system to ascertain patients satisfaction levels.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice