West Wing Doctors

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This is the first assessment for this service since its registration with CQC. This key question has been rated as Good.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive culture of safety, based on openness, honesty, and self-improvement. The provider had established processes to improve services based on learning, for example through investigation and learning from incidents.The provider had procedures for identifying, investigating and taking corrective actions to improve. The provider told us that since they started operating, they had not received any formal complaints. The provider had recorded 4 incidents since 2025. These had been investigated, appropriate action taken, and any relevant changes implemented.

There was a programme of audits in place which included infection prevention and control, prescribing, and record keeping audits.

There were processes in place for obtaining and recording information from new patients at the point of registration.

Information was shared with the patient’s NHS GP, and letters contained comprehensive details of, for example, consultations, clinical findings, and recommendations. Similarly, when patients were referred to other services, referrals contained detailed information to support continuity of care.

There was a clear pathway for the receipt and management of test results and patient correspondence.

There were policies and processes in place to safeguard patients, and protect them from harassment, abuse, discrimination, avoidable harm and neglect. Disclosure and Barring Service checks were carried out for all staff.

There were processes in place for managing emergencies. Staff knew where to locate emergency drugs and equipment. Checks on emergency drugs and equipment were carried out and recorded regularly.

The provider worked with patients to understand and manage risks. They undertook comprehensive consultations during which they discussed with patients their medical history, and ongoing symptoms. Patients were advised on risks related to their condition. Where high risks were identified, patients were urgently referred to other services.

All staff received training in basic life support.

The service operated from premises attached to a larger building, with responsibility for the building shared between the provider and the building management team. At the time of the assessment, there was insufficient clarity regarding the respective responsibilities for premises health and safety management. As a result, the provider was unable to supply all the documentation required to demonstrate that appropriate arrangements were in place.

We also identified that some equipment at the service had not been calibrated, however the provider took immediate action and arranged for the equipment to be calibrated during the assessment process.

Following the assessment, the provider obtained additional documentation from the building management team, providing assurance regarding the safety and maintenance arrangements for the premises. The provider also reviewed and strengthened governance arrangements by developing a policy that set out arrangements for ongoing oversight and regular review of premises health and safety, to ensure the service remained compliant.

Most staff had completed the training required for their roles, however some gaps were identified, including instances where training had not been completed at the appropriate level. Following the assessment, the provider took prompt action and provided evidence that all required training had since been completed. The provider also reviewed the factors contributing to these gaps and introduced a new policy, setting out clear training requirements alongside arrangements for monitoring and reviewing compliance going forward.

Our review of a sample of staff records identified that some documentation was incomplete. The provider responded by reviewing all records and supplying evidence that missing information had been obtained and updated. In addition, the provider implemented a new policy outlining required documentation, alongside monitoring and review processes to ensure records remained complete and up to date.

Staff told us they had enough resources and support to carry out their role safely and effectively.

The provider was subject to external appraisal and revalidation.

The provider assessed and managed the risk of infection. There were appropriate infection prevention and control (IPC) processes in place. IPC audits were regularly undertaken, although 1 finding in relation to lapsed IPC training had not been actioned in an appropriate timescale.

We found the premises and equipment to be clean, tidy and well maintained. Clinical sharps bins were dated and signed, and waste was appropriately managed by an external company. Personal protective equipment was available.

Medicines were stored securely and appropriately. A refrigerator previously used to store vaccines had been subject to regular temperature monitoring. At the time of the assessment, we were told that this refrigerator was no longer being used.

Staff regularly checked stock levels and expiry dates for medicines.

As part of our assessment a Care Quality Commission GP specialist advisor undertook a review of patient records at the service. Our review showed that medicines were effectively managed by the service. Appropriate prescriptions had been produced and documented clearly in records. Consultation notes were detailed and contemporaneous, including details of clinical decision-making, assessments undertaken, and relevant test results. Where referrals were required, letters were completed and recorded within the patient records, ensuring a clear audit trail of actions taken.

Where required, details of the assessment and outcomes were documented in a letter which was sent to the patient’s NHS GP.