The Care Quality Commission
  • Doctor
  • GP practice

Bluebell Surgery

Overall: Good read more about inspection ratings

Jack Andrews Drive, Colchester, Essex, CO4 9YN (01206) 855222

Provided and run by:
Dr Raman Chandel

Important: The provider of this service changed - see old profile

All Inspections

6 July 2023

During a monthly review of our data

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

25 October 2021

During a routine inspection

We carried out an announced inspection at Bluebell Surgery on 25 October 2021. Overall, the practice is rated as good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Requires Improvement

Following our previous inspection on 5 March 2019 the practice was rated requires improvement overall. Specifically, they were rated requires improvement for safe, effective and well-led services and good for caring and responsive services. We issued a requirement notice at this inspection for Regulation 17, Good Governance.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bluebell Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This was a comprehensive inspection to follow-up on the breaches of the regulations identified at the last inspection, the other areas where we told them they should improve, and re-rate the practice.

How we carried out the inspection/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 inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.

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

We found that:

  • The breaches found in the previous inspection had been complied with and actioned.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • We saw risk assessments were undertaken and actions taken when issues were found.
  • Patients received effective care and treatment that met their needs. The patient records we reviewed showed care pathways and protocols were well managed and followed.
  • Staff dealt with patients kindly and with respect, involving them in decisions about their care. This was explained to us when we spoke with patients when we visited the practice.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.

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

  • Continue to improve prescribing data.
  • Continue to improve childhood immunisation and cervical screening uptake.
  • Continue to work on the practice strategy to embed it into the business as usual at the practice.
  • Continue to develop an effective quality improvement programme, including clinical audit.

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

05/03/2019

During a routine inspection

We carried out an announced comprehensive inspection at Bluebell Surgery on 5 March 2019 as part of our inspection programme.

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 requires improvement overall and requires improvement for all population groups.

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

  • The practice did not have clear systems and processes to keep patients safeguarded from abuse. There was no clarity regarding who at the practice was the safeguarding lead.
  • Health and safety, fire safety and safeguarding systems to manage risk were not in place or up to date.
  • Appropriate standards of cleanliness and hygiene were being met. A lead for infection control had not been appointed and the annual audits and monitoring stated within their policy had not been carried out.

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

  • Patients received care and treatment that met their needs however, the practice had not audited the services they provided adequately, to be assured patient outcomes were improved.

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

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • However, the practice had not formally identified patients that were carers to ensure they had access to the care and support they needed.

We rated the practice as good for providing responsive servicesbecause:

  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The practice listened to their patients and organised and delivered services to meet their patients’ needs.
  • Patients could access care and treatment in a timely way.

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

  • The practice lacked regular clinical oversight, to ensure care and treatment was well-led.
  • The GP lead had the skills to deliver high-quality sustainable care however, did not have work time capacity for consistent oversight of all clinical and managerial work.

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 areas where the provider should make improvements are:

  • Improve the identification of carers to enable this group of patients access to the care and support they need.
  • Improve the uptake of patients for the national cancer screening programme in particular, those in relation to breast and bowel screening.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care