The Care Quality Commission
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Archived: Husbands Bosworth Surgery

Overall: Good read more about inspection ratings

Kilworth Road, Husbands Bosworth, Lutterworth, Leicestershire, LE17 6JZ (01858) 880522

Provided and run by:
Market Harborough and Bosworth Partnership

Important: This service is now registered at a different address - see new profile

All Inspections

4 October 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 Husbands Bosworth Surgery on 4 October 2016. Overall the practice is now rated as Good.

The purpose of this inspection was to ensure that sufficient improvement had been made following the practice being placed in to special measures as a result of the findings at our inspection on 28 January 2016 when we found the practice to be inadequate overall.

At this most recent inspection we found that extensive improvements had been made and specifically, the ratings for providing a safe and well led service had improved from being inadequate to good. The rating for providing an effective, caring and responsive service had improved from requiring improvement to good.

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

  • The practice had a governance framework in place with systems and processes in place to support the delivery of their strategy.

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. The practice had put an effective system in place to safeguard adults and children from abuse.
  • Overall risks to patients were assessed and well managed.
  • The leadership and systems and processes for the dispensary had been reviewed.
  • The system in place for palliative care monitoring and review had been reviewed and new processes put in place.
  • The practice now had a quality improvement programme in place which included a rolling programme for clinical audit cycles.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • CQC comments cards were reviewed told us that patients 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • 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 necessary emergency medicines and equipment are available and suitable for use at all times.

  • Increase the testing of fire alarm and legionella temperature control monitoring to a monthly basis as per recognised national guidance.

  • When reviewing policies and procedures, add review date and document and amendments made.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

28 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Husbands Bosworth Surgery on 28 January 2016. Overall the practice is rated as inadequate.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were not thorough enough. Patients did not always receive a verbal and written apology.

  • There was a limited governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.

  • The practice did not have a structured or robust approach for dealing with safeguarding.

  • The practice did not have a robust or adequate system in place for palliative care monitoring and review.

  • Data showed patient outcomes were above average compared to the locality and nationally. Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
  • The majority of patients said they were treated with compassion, dignity and respect. However, some felt the attitude of reception staff needed addressing.
  • Urgent appointments were usually available on the day they were requested.
  • The practice had a proactive patient participation group and have sought feedback from patients.

  • There was a documented leadership structure for the Husbands Bosworth surgery but it was not clear who took overall responsibility for the surgery.

The areas where the provider must make improvements are:

  • Introduce a robust system for reporting, recording, acting on and monitoring significant events, incidents and near misses and complaints.

  • Implement a robust system for dealing with safety alerts.

  • Have a robust system in place to ensure that patients are safeguarded from abuse and improper treatment.

  • Ensure the practice has a robust quality improvement programme which includes completed clinical audit cycles.

  • Ensure there is adequate leadership in the dispensary and systems and processes in the dispensary are robust.
  • Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
  • Clarify the leadership structure for the surgery and ensure there is leadership capacity to deliver all improvements.
  • Provide staff with appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice and which identify the responsible person.
  • Ensure there are mechanisms in place to seek feedback from staff and patients and this feedback is responded to.

The areas where the provider should make improvement are:

  • Ensure standard operating procedures for the dispensary include a competency section.
  • Ensure competencies of dispensary staff are checked appropriately
  • Ensure actions from infection control audits are recorded and implemented.
  • Have in place a robust cleaning schedule to give assurance specific rooms are being cleaned.
  • Improve the system for the identification of carers
  • Embed a formalised process for the recording of minutes of meetings.

I am placing this practice in special measures. Where a practice is rated as inadequate for one of the five key questions or one of the six population groups and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures.

Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made so a rating of inadequate remains for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or varying the terms of their registration within six months if they do not improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice