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Blundell Park Surgery Requires improvement

The provider of this service changed - see old profile

We are carrying out a review of quality at Blundell Park Surgery. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 7 January 2021

We inspected the practice on 9 July 2019 and rated the practice Inadequate overall. The practice was put into special measures and enforcement action was taken.

We followed up the enforcement action with an announced focused inspection on 4 December 2019. We found that the practice had made some improvements in relation to the breaches in regulation.

We inspected again on 26 February 2020 and found that some of the improvements we saw in the follow-up inspection had not been sustained and in addition we found some other areas of concern. The practice was rated as requires improvement overall and requires improvement for the key questions safe and effective, good for caring and responsive and inadequate for well led and the practice remained in special measures.

We carried out an announced comprehensive inspection at Blundell Park Surgery on 18 November 2020 as part of our inspection programme.

At this inspection we followed up on breaches of regulations identified at the previous inspection on 26 February 2020.

This inspection looked at the following key questions:

Are services safe?

Are services effective?

Are services caring?

Are services responsive?

Are services 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 organisations.

We have rated this practice as Requires Improvement overall.

We have rated the practice requires improvement overall because the practice had made improvements since our inspection in February 2020 and addressed areas relating to previous breaches of regulation. However, some governance arrangements had not been sufficiently implemented and embedded to prevent some additional areas for improvement that we found at this inspection.

We rated the practice as Requires Improvement for providing safe services because:

  • The practice had assessed fire safety and Legionella risk and developed an action plan, but they had not implemented all the actions.
  • The practice did not always have effective systems for the appropriate and safe use of medicines, including medicines optimisation in respect of vaccine storage, actioning medicine safety alerts and undertaking medicine reviews and monitoring checks.

We rated the practice as Requires Improvement for providing effective services because:

  • Patients’ needs were assessed, but care and treatment was not always delivered in line with current standards and evidence-based guidance in relation to reviews of patients with long term conditions and a learning disability.
  • Some performance data was below local and national averages in relation to care and treatment of patients with long term conditions.

We rated the practice as Requires improvement for providing caring services because:

  • Data showed patient satisfaction had deteriorated.
  • The provider had not undertaken its own patient satisfaction survey to monitor the effectiveness of their improvement actions.

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

  • The practice had made improvements since our inspection in February 2020 and addressed areas relating to previous breaches of regulation. However, we found additional areas of concern related to the management and oversight of the service.
  • There was compassionate, inclusive and effective leadership at all levels, but leaders could not always demonstrate that they had the capacity and skills to deliver high quality sustainable care.
  • The practice had a clear vision, but it was not always supported by a credible strategy.
  • The overall governance arrangements were not always effective.
  • The practice did not have clear and effective processes for managing all identified risks, issues and performance.
  • The practice did not always act on appropriate and accurate information.

We rated population groups people with long term conditions, families, children and young people and working age people as requires improvement. This was because we were not assured that regular medication and long-term condition reviews were being undertaken for all patients who required them, and childhood immunisations and cancer screening data had not improved. Other population groups were rated as good.

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

  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way. Although data had deteriorated in relation to patient satisfaction the practice had acted to improve since this data was gathered.

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Continue with the refurbishment of the practice as planned and include improvement to communal areas, the blinds and an area of damp wall in the nurse’s room.

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

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

Inspection areas


Requires improvement


Requires improvement


Requires improvement




Requires improvement
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people


Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable