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Review carried out on 9 September 2021

During a monthly review of our data

We carried out a review of the data available to us about Western Avenue Surgery on 9 September 2021. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Western Avenue Surgery, you can give feedback on this service.

Review carried out on 19 September 2019

During an annual regulatory review

We reviewed the information available to us about Western Avenue Surgery on 19 September 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

During a routine inspection

This practice is rated as Good overall. (Previous rating July 2017 – Requires Improvement).

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Western Avenue Surgery on 11 July 2017. The overall rating for the practice was requires improvement. The practice was rated requires improvement for all domains and population groups. The full comprehensive report on the July 2017 inspection can be found by selecting the ‘all reports’ link for Western Avenue Surgery on our website at

This inspection was an announced comprehensive inspection carried out on 2 July 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 11 July 2017.

This report covers our findings in relation to those requirements and additional improvements made since our last inspection. We found the practice had made improvements since our last inspection.

Overall the practice is now rated as good.

At this inspection we found:

•The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.

•The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.

•Staff involved and treated patients with compassion, kindness, dignity and respect.

•Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

•There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

•Continue efforts to improve patient scores from the national GP survey.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection carried out on 11 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Western Avenue Surgery on 11 July 2017. Overall the practice is rated as requires improvement.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events. However, significant events and near misses were not formally discussed and actioned as the practice held no formal clinical meetings.
  • The practice had some defined and embedded systems to minimise risks to patient safety.
  • Staff were aware of current evidence based guidance. Some staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment. However, the practice did not have training records for locum staff.
  • The practice nurse had not received a Disclosure and Barring Service check before starting work at the practice.
  • Results from the national GP patient survey showed patients considered the practice to be performing well in some areas, but below average in most. The practice had not addressed this feedback.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat most patients and meet their needs. However, accessibility for patients with a physical disability was limited.
  • 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.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvements are:

  • Develop effective systems and processes to ensure safe care and treatment including significant event processes being clear and reviewed, and that discussions occur to ensure that events are not missed. This should also include ensuring prescription security where they are taken from the premises.

  • Develop effective systems and processes to ensure the dignity and respect of patients is maintained, including acting on patient feedback.

  • Develop effective systems and processes to ensure good governance including ensuring that formal communication lines are established between clinicians.

  • Develop effective systems and processes to ensure staffing is managed in line with regulations, including ensuring that all staff Disclosure and Barring Service status is checked and recorded and that photographic evidence of staff identities is retained. This should also include ensuring that staff have completed training.

In addition the provider should:

  • Review clinical exception reporting at the practice which is higher than the national average.
  • Ensure patients privacy is maintained when intimate examinations are carried out.
  • Develop systems to identify carers so their needs can be identified and met.
  • Improve access for patients with disabilities.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice