We carried out an announced inspection at Bridgewater Surgeries on 5 December 2019. The practice was rated as good overall; however, they were rated as requires improvement for providing well-led services.
The report for the December 2019 inspection can be found by selecting the ‘all reports’ link for Bridgewater Surgeries on our website at www.cqc.org.uk
This inspection carried out on 18 July 2022 was a desk-based review to confirm that the practice had made the necessary improvements in the areas we identified at our previous inspection in December 2019.
We based our judgement of the quality of care at this service on a combination of:
- Information sent to us from the provider.
- Information from our ongoing monitoring of data about services.
We rated the practice as good for providing well-led services because:
- The practice had put an action plan in place to improve the systems and processes to ensure good governance.
- The practice made use of an online platform to monitor practice activities. This included the ongoing monitoring of staff training, staff immunisation records and the professional registration of all clinical staff.
- A new management structure was in place.
Additionally, where we previously told the practice they should make improvements our key findings were as follows:
- There had been a decline in the uptake of childhood immunisations from the previous inspection in December 2019 when the practice met the minimum 90% uptake for four out of five childhood immunisations and exceeded the 95% World Health Organisation (WHO) target for one childhood immunisation. At this inspection the practice was below the minimum 90% target for three out of five of the childhood immunisations with all five below the WHO 95% target. The practice had an action plan in place to increase the uptake of childhood immunisations. For example,
- The nursing staff telephoned parents or guardians of children due immunisations to book an appointment.
- They telephoned the parents or guardians of children not brought in for immunisation appointments to discuss the benefits of immunisation and to book appointments. If there was no response to telephone calls, they would write to the parent or guardian.
- A discussion regarding immunisations was held at the eight week baby check and the first immunisations were given at the same time if able.
- they matched immunisation records for children registered from abroad to ensure medical records were complete.
- The practice was below the 80% target set by the UK Health and Security Agency for cervical screening. However, there had been an increase since the previous inspection. For example, the percentage of persons eligible for cervical cancer screening at a given point in time who were screened adequately within a specified period had increased from 67% at the December 2019 inspection to 75% at this inspection. The practice had an action plan in place to increase the uptake of cervical screening. For example,
- The practice sent reminder letters or text messages after the patient had been sent their initial invite letter.
- Appointments for cervical screening were available early morning, evenings and on Saturdays.
- Alerts were used on the patient clinical system to encourage clinicians to prompt patients that they were overdue cervical screening opportunistically if they had attended for another matter.
- The practice planned to complete an audit of non-attenders to help them identify the reasons. This would include timings of appointments, disabilities, language barriers and cultural beliefs.
Whilst we found no breaches of regulations, the provider should:
- Continue to take actions to increase the uptake of childhood immunisations and cervical screening.
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