Archived: West End Clinic

Updated 6 October 2016

West End Clinic is located in Rossington on the outskirts of Doncaster. The practice provides services for 4819 patients under the terms of the NHS Personal Medical Services contract. The practice catchment area is classed as within the group of the third more deprived areas in England. The age profile of the practice population is similar to other GP practices in the Doncaster Clinical Commissioning Group (CCG) area.

The practice has one female GP who works six sessions per week and is supported by two male locum GPs who cover three sessions per week. They are supported by an advanced nurse practitioner, a practice nurse, a healthcare assistant a practice manager, assistant practice manager and a team of reception and administrative staff. 

The practice is open between 8am to 6pm Monday to Friday. Early morning appointments are available with a GP on Wednesday from 7am. Appointments with GPs, practice nursing staff and the healthcare assistants are available during the opening hours. A phlebotomy service with the healthcare assistant is available daily. Patients with diabetes can book an appointment with a visiting GP with a specialist interest in diabetes in a monthly clinic held at the practice.

In addition to pre-bookable appointments that could be booked up to six weeks in advance, urgent appointments were also available for people that needed them. 

When the practice is closed calls were answered by the out-of-hours service which is accessed via the surgery telephone number or by calling the NHS 111 service.

As part of the Care Quality Commission (Registration) Regulations 2009: Regulation 15 we noted GP partners registered with the Care Quality Commission as the partnership did not reflect the GP partners currently at the practice. We were told this would be addressed following the inspection and the appropriate applications and notifications submitted. 

Updated 6 October 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at West End Clinic on 19 July 2016. Overall the practice is rated as inadequate.

Our key findings across all the areas we inspected were as follows: 

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, there was insufficient attention to issuing acute prescriptions. Administrative staff would issue prescriptions for medicines under instruction from the GP to then review and sign. Other staff had permissions to issue prescriptions without completing relevant independent prescribing courses.
• Staff were clear about reporting incidents. However a thorough investigation of significant events and analysis was not undertaken and appropriate action taken to prevent them from happening again. Incidents reported were not linked to review of the relevant policy or procedure as part of the investigation process.
• Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement and there was no evidence that the practice was comparing its performance to others; either locally or nationally.
• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
• The practice had a leadership structure, with insufficient leadership capacity and limited formal governance arrangements.

Areas identified to support improvement are:

• To review and introduce effective processes for recording, acting on and monitoring significant events, incidents and near misses.
• Take action to address identified concerns with prescribing of medicines and ensure patient group directives are in date and signed by an authorised person.  Prescription processes need to comply with NHS Protect security of prescriptions and all prescriptions tracked through the practice.
• Carry out clinical audits including re-audits to ensure improvements have been achieved.
• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
• Provide staff with appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.
• All staff to complete training in infection prevention and control and information governance.
• Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements.

• Review and implement a system to record actions taken in response to  National Institute for Health and Care Excellence (NICE) and other best practice guidelines.
• Provide information about chaperones to patients in individual consultation and treatment rooms.
• Review the system for recording communication relating to complaints with people and ensure it is not documented within the patient record.
• Maintain adequate records of training and indemnity arrangements for locum staff.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the service from operating. Special measures will give people who use the service the reassurance that the care they get should improve.

We identified regulatory breaches within the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 during this inspection.  They are Regulation 12 Safe care and treatment; Regulation 17 Good Governance and Regulation 18 Staffing. The Care Quality Commission is unable to take enforcement action against the provider regarding these breaches as they are registered with us as partnership but should be registered as a sole provider. Immediate steps are being taken by the provider to rectify the situation by submitting a registration application to become a sole provider.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Updated 6 October 2016

The practice is rated as inadequate for the care of people with long-term conditions.

The provider was rated as inadequate for safety and for well-led and requires improvement for being effective and responsive. The issues identified as requiring improvement overall affected all patients including this population group.

There were, however, examples of good practice:

• Nursing staff had lead roles in long term condition management and patients at risk of hospital admission were identified as a priority.
• Performance for diabetes related indicators was 1%below the CCG average and 6% above the national average.
• All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Updated 6 October 2016

The practice is rated as inadequate for the care of families, children and young people.

The provider was rated as inadequate for safety and for well-led and requires improvement for being effective and responsive. The issues identified as requiring improvement overall affected all patients including this population group.

There were, however, examples of good practice:

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency attendances.
• The practice’s uptake for the cervical screening programme was 84%, which was above the CCG average of 82% and the national average of 81%.

Updated 6 October 2016

The practice is rated as inadequate for the care of older people.

The provider was rated as inadequate for safety and for well-led and requires improvement for being effective and responsive. The issues identified as requiring improvement overall affected all patients including this population group.

There were, however, examples of good practice:

• It was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
• The GP held a bi-monthly clinic at the local care homes incorporating medication and long term condition reviews along with regular appointments.

Updated 6 October 2016

The practice is rated as inadequate for the care of working-age people (including those recently retired and students).

The provider was rated as inadequate for safety and for well-led and requires improvement for being effective and responsive. The issues identified as requiring improvement overall affected all patients including this population group.

There were, however, examples of good practice:

• The practice offered online services.

Updated 6 October 2016

The provider was rated as inadequate for safety and for well-led and requires improvement for being effective and responsive. The issues identified as requiring improvement overall affected all patients including this population group.

There were, however, examples of good practice:

• 77% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which is below the national average of 84%.
• Of those patients with complex mental health illness 97% had their care reviewed in a face to face meeting in the last 12 months which is above the national average of 90%.
• The practice worked with multidisciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
• The practice carried out advance care planning for patients with dementia.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

Updated 6 October 2016

The practice is rated as inadequate for the care of people whose circumstances may make them vulnerable.

The provider was rated as inadequate for safety and for well-led and requires improvement for being effective and responsive. The issues identified as requiring improvement overall affected all patients including this population group.

There were, however, examples of good practice:

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients.
• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.
• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and notices how to contact relevant agencies in normal working hours and out of hours were on display in the treatment and consultation rooms.