We carried out an announced comprehensive inspection at Bellegrove Surgery 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.

The overall rating for this practice was requires improvement due to concerns in providing safe and well-led services. However, the population groups were rated as good because patients were able to access timely and effective care and treatment.

We rated the practice as inadequate for providing safe services because:

• The practice did not have clear systems and processes to keep patients safe.
• The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
• Staff recruitment records were incomplete.
• The practice did not have appropriate systems in place for the management of one particular high risk medicine.

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

• The overall governance arrangements were ineffective.
• The practice did not always have clear and effective processes for managing risks.

We rated the practice as good for providing effective, caring and responsive services because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• 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:

• The practice should ensure that fire drills are carried out in order to adhere to all fire regulations.
• The practice should ensure that an effective system of tracking and monitoring safety alerts is implemented.
• The practice should improve the identification of carers to enable this group of patients to access the care and support they need.

• The practice should establish a schedule of formal staff meetings.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups, it will be re-inspected no longer than six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

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

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Letter from the Chief Inspector of General Practice:

We carried out an announced comprehensive inspection at Dr WA Cotter + Dr JCJM Bohmer –Laubis’ practice on 26 August 2015. Overall the practice is rated as good.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

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. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• The practice had identified risks and had implemented systems to mitigate risks.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.

• Patients said they 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.
• Regular multi-disciplinary team meetings were in place at the practice.

• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider should

• Ensure that all outstanding appraisals for non-clinical staff are completed..

• The practice should ensure that it adheres to all fire regulations, specifically by carrying out fire drills.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice