Bousfield Health Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Leaders demonstrated that they understood the challenges to quality and sustainability. They had acted for the findings of the previous inspection and improvements to services were made. Staff reported that leaders were visible and approachable, and they reported feeling able to raise concerns without fear of retribution. We found improved governance and risk management systems and processes. We saw information was used to monitor and improve the quality of care. The practice had an active Patient Participation Group. Learning was shared effectively and used to make improvements. There were named leads in place for key areas and staff were clear about their roles and responsibilities.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The staff we spoke with were aware of the vison and values of the provider, although they did confirm they had not been consulted for the development of these. Staff stated the provider encouraged candour, openness and honesty and staff were encouraged to report concerns and incidents. Feedback from staff was very positive about working at the practice. Staff told us the management team were approachable and they felt confident issues raised would be responded to. Staff told us they were well supported with training and development. They said they felt supported, respected and valued. They told us they felt proud to be part of the practice team.

A statement of the vision and values were available to staff, and this had been discussed at staff meetings. Regular practice meetings took place, and this included all staff groups. The practice had a Whistle Blowing Policy which included a Freedom to Speak Up Guardian for staff to report concerns to. All reported concerns were reviewed by the provider.

We did not look at this quality statement for this assessment. The score for this quality statement is based on the previous inspection carried out in September 2023.

We did not look at this quality statement for this assessment. The score for this quality statement is based on the previous inspection carried out in September 2023.

We did not look at this quality statement for this assessment. The score for this quality statement is based on the previous inspection carried out in September 2023.

We did not look at this quality statement for this assessment. The score for this quality statement is based on the previous inspection carried out in September 2023.

We did not look at this quality statement for this assessment. The score for this quality statement is based on the previous inspection carried out in September 2023.

We did not look at this quality statement for this assessment. The score for this quality statement is based on the previous inspection carried out in September 2023.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews.

At our last inspection we identified that while improvements were made relating to the governance, management and sustainability of the practice, further improvements were required. We noted that the practice manager did not have access to full data and information to carry out their roles effectively. Since the inspection the provider had reviewed the governance systems and structures and made changes to how these were implemented. There were increased local management of processes to manage performance. The practice had a quality improvement programme in place which identified the areas that required improvement from the last inspection. This was monitored by the practice manager and provider. There were arrangements for identifying, managing and mitigating risks. For example, the practice had a process in place for managing significant events and near misses. Such events were reported by staff and discussed at staff meetings so that learning could take place. Prior to inspection the provider shared example of risk assessments regularly undertaken by the practice, for example, environmental risk assessments to ensure the premises was safe. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

We did not look at this quality statement for this assessment. The score for this quality statement is based on the previous inspection carried out in September 2023.

We did not look at this quality statement for this assessment. The score for this quality statement is based on the previous inspection carried out in September 2023.

We did not look at this quality statement for this assessment. The score for this quality statement is based on the previous inspection carried out in September 2023.

We did not look at this quality statement for this assessment. The score for this quality statement is based on the previous inspection carried out in September 2023.

Regular staff meetings took place during which patients’ complaints and significant event discussions took place to identify learning and actions that needed to be taken.

At our last inspection in September 2024, we identified that detailed information relating to management of significant events was not made available to relevant members of the staff team. At this assessment we found this information was readily available and reviewed by the practice team. There were systems and processes in place to encourage continuous learning and improvement. Audits were undertaken for example, an audit of urgent suspected cancer (USC) referrals to secondary care for investigation and possible diagnosis to ensure unnecessary delays were picked up by the practice for follow-up.