West Wing Doctors

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

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

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service. The provider had developed a vision and set of values which expressed their drive to provide high-quality, individually tailored care, with humanity and respect. Feedback from staff indicated they were familiar with the vision and values.A business plan had been developed which included an overview of risk management, quality control processes, and succession planning.

Staff told us that the provider was visible and approachable and that they felt supported by them.

The provider told us that they encouraged a culture of openness and that they had had an open-door policy which allowed staff to approach them directly; this was corroborated by feedback we received from staff.

The provider demonstrated an understanding of the duty of candour and operated in an open and transparent manner.

Staff told us they knew how to raise concerns and felt confident to do so. They told us that the small size of the team enabled frequent and ongoing discussions, and a culture of openness where information was shared promptly, and any issues were discussed as they arose.

The provider demonstrated a commitment to promoting equality, diversity, and inclusion within the workforce. Equality and diversity training formed part of the mandatory training requirements, helping staff to understand their responsibilities and contribute to an inclusive working environment.

Supporting policies included a staff wellbeing policy and a stress management policy, which outlined the provider’s commitment to the health, safety, and welfare of staff. These policies also included provisions for flexible working arrangements and processes for addressing any bullying, harassment, or discrimination. Staff spoke positively about the workplace culture.

The provider had established effective governance and management systems to support the delivery of safe and high-quality care.

The provider supported staff, and all staff were clear on their individual roles and responsibilities. Staff told us they had access to policies and procedures to support them within their role. Policies and procedures were regularly reviewed.

The provider operated with a small staff team, which supported effective communication. Although formal planned meetings were held regularly, staff told us that the size of the team enabled frequent, informal communication and ongoing discussions about patient care and service delivery.

There were effective clinical governance processes in place, including maintaining accurate and contemporaneous patient records, and clear protocols for sharing information with relevant professionals and services. The provider undertook clinical audit activity and had systems in place to review incidents and near misses, ensuring that learning was identified and embedded into practice.

However, we identified gaps in oversight relating to staffing and premises records, where documentation was not consistently maintained. The provider acknowledged the concerns identified and responded in a prompt and constructive manner, taking appropriate steps to address immediate concerns as well as introducing measures to support ongoing compliance and reduce the potential for similar issues to arise in the future.

There was a business continuity plan and this detailed arrangements in place in the event of certain incidents.

Staff received training in information governance and were aware of the importance of patient confidentiality and information security.

The provider worked effectively in partnership with other services and demonstrated a clear understanding of the importance of collaborative working to achieve positive outcomes for patients.

Evidence showed there were established processes for maintaining regular communication with external organisations, including when making referrals, sharing information, and seeking specialist advice and guidance.

Feedback from other healthcare professionals showed that the provider communicated effectively and maintained constructive working relationships to support the delivery of coordinated care that was responsive to patients’ needs.

The provider demonstrated a proactive and embedded culture of learning, improvement and innovation. They continually sought opportunities to enhance patient outcomes through the application of emerging evidence and best practice. For example, the provider had introduced a recognised screening test, supported by current clinical guidance, which was not routinely available through standard NHS pathways. This decision was based on the potential of this test to improve the detection of clinically significant prostate cancer.

Early evidence of the impact of this approach was seen in the identification of prostate cancer in 5 patients over an 8-month period, whose results from standard testing methods would not have indicated the need for further investigation. These patients were subsequently referred for specialist assessment and treatment, enabling earlier clinical intervention. This approach was also supported and endorsed by a local specialist urology consultant, who provided ongoing specialist advice and support where there was any clinical uncertainty.

The provider subscribed to various medical journals to keep up to date with the latest guidance and research. Quality improvement processes were also in place, including audits covering record keeping and adherence to best practice guidelines, as well as learning from significant events and incidents which had prompted improvement.