The Care Quality Commission
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  • GP practice

Archived: Westbourne Surgery

Overall: Good read more about inspection ratings

11a St James Road, Marsh, Huddersfield, West Yorkshire, HD1 4QR 0844 387 8280

Provided and run by:
Westbourne Surgery

Important: The provider of this service changed. See new profile

All Inspections

6 April 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Westbourne Surgery on 19 August 2015. The overall rating for the practice was good. However, a breach of the legal requirements was found which resulted in the practice being rated as requires improvement for providing safe services. The full comprehensive report on the August 2015 inspection can be found by selecting the ‘all reports’ link for Westbourne Surgery on our website at www.cqc.org.uk.

In addition to the breach of regulation, at the inspection on 19 August 2015 we also said the practice should consider the following area:

  • The practice should review the provision of emergency equipment and undertake a risk assessment in regard to the decision not to have a supply of emergency oxygen or a defibrillator on the premises.

This inspection was an announced focused inspection carried out on 6 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach of regulation that we identified in our previous inspection on 19 August 2015. This report covers our findings in relation to those requirements.

The practice had not made sustained improvements to meet the legal requirements in the key question of safe and remains rated as requires improvement.

Our key findings were as follows:

  • The practice had not undertaken an assessment for the risk of legionella, fire safety, emergency equipment or undertaken an infection prevention and control (IPC) audit or completed a fire drill within the last 12 months. Mandatory refresher training in fire safety and IPC had not been completed by relevant staff.

The areas where the provider must make improvement are:

  • The provider must assess the risks to the health and safety of service users and do all that is reasonably practicable to mitigate any such risks. Risk assessments to monitor the safety of the premises in respect of infection prevention and control (IPC) and legionella had not been completed. A supply of emergency oxygen was not held at the practice and no risk assessment had been completed to support this decision.

  • Ensure relevant staff update their mandatory training in respect of fire safety, fire evacuation and IPC to ensure they have the appropriate training to meet their learning needs and to cover the scope of their work.

The areas where the provider should make improvement are:

  • The practice should risk assess and review the arrangements for emergency equipment as there was no defibrillator held at the practice.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

19 August 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Westbourne Surgery on 19 August 2015. Overall the practice is rated as good.

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.
  • Some risks to patients were assessed and managed, with the exception of those relating to legionella, infection prevention and control and fire safety assessments.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles, with the exception of infection prevention and control training. 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.
  • Patients said there was continuity of care, with urgent appointments available the same day.
  • 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 must:

  • Ensure a Legionella risk assessment is completed and action plan implemented in accord with the findings.
  • Ensure an infection prevention and control audit is completed and action plan implemented in accordance with the findings.
  • Ensure a fire assessment of the premises is completed and action plan implemented in accordance with the findings.

In addition the provider should:

  • Risk assess and review the absence of oxygen and a defibrillator on the premises to ensure the safety and welfare of patients.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice