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Inspection Summary


Overall summary & rating

Good

Updated 20 November 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at West Coker Surgery (then known as Westlake Surgery) on 23 November 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for West Coker Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 1November 2017 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 in November 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice and all population groups are now rated as good.

Our key findings were as follows:

  • Staff had a record of appropriate training relevant to their role, including up to date training in safeguarding adults, basic life support, fire safety and infection control.
  • There were effective arrangements in place to assess, monitor, manage and mitigate risks in respect of health and safety. These arrangements included systems for addressing Medicines and Healthcare products Regulatory Agency (MHRA) safety alerts, reviewing patients’ medicines, the risk assessment of legionella; and a comprehensive business continuity plan was in place.
  • Arrangements for engaging patients with a learning disability and those diagnosed with a mental health condition were in place which ensured they had the appropriate care and support and attended annual reviews.
  • Systems were in place to assess, monitor and improve the quality and safety of the service, including those for up to date record keeping, including for staff training and for significant events; for a rolling programme quality improvement, such as clinical audits; and for engaging with patients, such as through a patient participation group.
  • Arrangements to identify and support carers were in place.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 20 November 2017

At our inspection on 23 November 2016, we found:

  • Staff understood their responsibilities to raise concerns, and to report incidents and near misses. However, the system used for recording significant events and that actions were completed was not consistently implemented.
  • Although risks to patients were assessed, some systems to address these risks were not implemented well enough to ensure patients were kept safe. For example, we found the medicine reviews were not up to date for all patients; and arrangements for safety alerts did not ensure patient safety.
  • The practice did not have a legionella risk assessment or a business continuity plan in place; and there were gaps in the records of staff recruitment and training.

At this inspection on 1 November 2017, we found:

  • appropriate incidents were being recorded consistently as significant events and a spreadsheet was in use to monitor progress, including that all actions were completed.
  • there were effective arrangements in place to assess, monitor, manage and mitigate risks in respect of health and safety. These arrangements included systems for reviewing patients’ medicines, which were all up to date; and for addressing Medicines and Healthcare products Regulatory Agency (MHRA) safety alerts.
  • a risk assessment of legionella, along with monthly monitoring of water temperatures was in place, as was a comprehensive business continuity plan.
  • staff had a record of appropriate training relevant to their role, including up to date training in safeguarding adults, basic life support, fire safety and infection control.

Effective

Good

Updated 20 November 2017

At our inspection on 23 November 2016, we found:

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average compared to the national average. However, we found some patients who had a learning disability or who had a mental health condition had not received a review of their health or care.
  • There was no evidence that audit was driving quality improvement. Two clinical audits had been carried out in the last 12 months but were not full cycle audits and did not demonstrate improved outcomes for patients.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment. There was evidence of appraisals and personal development plans for all staff. However, not all staff had a record of up to date training relevant to their roles and responsibilities. For example, there was little or no record of staff training in infection control, basic life support, fire safety and safeguarding adults.

At this inspection on 1 November 2017, we found:

  • arrangements for engaging patients with a learning disability and those diagnosed with a mental health condition were in place to ensure they had the appropriate care and support. We saw that a programme of annual reviews was in place.
  • systems were in place to assess, monitor and improve the quality and safety of the service, including a rolling programme quality improvement. We saw three full cycle clinical audits had been completed and evidence of improved outcomes for patients.
  • improved systems were in place for record keeping. We saw that staff had a record of appropriate training relevant to their role, including up to date training in infection control, basic life support, fire safety and safeguarding adults.

Caring

Good

Updated 20 November 2017

Responsive

Good

Updated 20 November 2017

Well-led

Good

Updated 20 November 2017

At our inspection on 23 November 2016, we found:

The practice encouraged a culture of openness and honesty. The practice had systems in place for notifiable safety incidents, however, this was not implemented well enough to ensure information was shared with all relevant staff and that appropriate action was taken.

The practice had a number of policies and procedures to govern activity, but some of these could not be located on the day of inspection and we saw some were overdue for review.

There were inadequate arrangements for record keeping, including for staff training and; for recording significant events consistently and completely; for a rolling programme quality improvement, such as clinical audits; and for engaging with patients, such as through a patient participation group.

At this inspection on 1 November 2017, we found:

  • there were effective arrangements in place for addressing notifiable safety incidents; and to ensure information was shared with all relevant staff, including locum GPs, and that appropriate action was taken.
  • improved systems were in place for record keeping, including for staff training and for recording significant events. We saw that policies had been reviewed and were up to date, including policies for safeguarding children and vulnerable adults.
  • arrangements were in place for a rolling programme quality improvement, including clinical audits.
  • Improvements in the arrangements for engaging with patients were in place, including through a patient participation group and systems to identify and support carers. We saw evidence of positive feedback from patients, including above average satisfaction scores in the latest GP patient survey results.
Checks on specific services

People with long term conditions

Good

Updated 20 November 2017

The provider had resolved the concerns for safe, effective and well-led services identified at our inspection on 23 November 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Families, children and young people

Good

Updated 20 November 2017

The provider had resolved the concerns for safe, effective and well-led services identified at our inspection on 23 November 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Older people

Good

Updated 20 November 2017

The provider had resolved the concerns for safe, effective and well-led services identified at our inspection on 23 November 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Working age people (including those recently retired and students)

Good

Updated 20 November 2017

The provider had resolved the concerns for safe, effective and well-led services identified at our inspection on 23 November 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People experiencing poor mental health (including people with dementia)

Good

Updated 20 November 2017

The provider had resolved the concerns for safe, effective and well-led services identified at our inspection on 23 November 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People whose circumstances may make them vulnerable

Good

Updated 20 November 2017

The provider had resolved the concerns for safe, effective and well-led services identified at our inspection on 23 November 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.