Westwood Clinic

We carried out a comprehensive inspection of Westwood Clinic on 13 December 2018. The practice was rated as inadequate overall with ratings of inadequate for providing safe and well led services, requires improvement for providing effective and caring services and good for providing responsive services. As a result of the findings on the day of the inspection the practice was issued with a warning notice for Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance).

We carried out a comprehensive inspection of Westwood Clinic on 9 July 2019. The practice was rated as inadequate overall with ratings of inadequate for providing safe, effective, and well led services, requires improvement for caring services and good for responsive services. Following our announced comprehensive inspection on 9 July 2019, we took urgent action to suspend Westwood Clinic’s CQC registration and prevent the provider from delivering regulated activities. During the period of suspension, a caretaking practice was put in place by the local Clinical Commissioning Group and NHS England to ensure delivery of services for patients and to implement improvements. A further inspection was completed on 13 August 2019 to follow up on the breaches of regulation. Following this inspection, we found the practice had made sufficient improvements to satisfy the suspension notice and therefore we lifted the provider’s suspension and the caretaking arrangement ceased.

You can read our findings from our all of our previous inspections by selecting the ‘all reports’ link for Westwood Clinic on our website at .

We carried out an announced comprehensive inspection at Westwood Clinic on 21 January 2020. This inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting regulatory requirements.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

At this inspection we found:

• We found the practice had implemented a number of governance structures and systems since our previous rated inspection published August 2019. However, due to the time since last inspection it was not possible to evidence improvements had been fully embedded.
• We saw the practice had made improvements including; completion of a significant number of overdue medicine reviews, a review of consultation documentation, over-arching management processes and learning from significant events.
• Childhood immunisation uptake rates were above the World Health Organisation (WHO) targets with a range of 97% to 98%.
• We found the practice had started to implement a number of audits, including two-cycle audits, to highlight areas where improvement is required.
• Patients we spoke with told us they had seen improvements in the practice since the previous inspection. In addition to this we received 26 comment cards which were wholly positive about the service.

At this inspection, the practice was rated as requires improvement for providing safe services because:

• We found the fire risk assessment was not sufficiently detailed. For example, consideration of the safe storage of flammable gases and combustible materials were not documented in the review. The provider could not demonstrate assurance that the assessment had been undertaken by a suitably competent person and that all relevant risks had been identified and acted upon.
• The practice had not completed and documented a health and safety risk assessment. In addition to this, actions relating to a premises and security risk assessment had not been completed.

At this inspection, the practice was rated as requires improvement for providing effective services because:

• At our previous rated inspection published August 2019 we reviewed training records and found members of staff had completed all of their training on one day. At this inspection we found this had continued and one member of staff had completed 24 modules of training on one day during a weekend. Staff also told us that they were not given protected learning time.
• The practice’s uptake of cervical, breast and bowel cancer screening was lower than the CCG and England averages.
• The practice’s Quality Outcomes Framework (QOF) performance evidenced a higher than average exception reporting rate. The practice had made changes to their exception reporting rate process, however, there was no evidence available on the day of the inspection to show the new processes had made improvements.
• We reviewed patient records and found there was an inconsistent approach to documenting patient care plans.

At this inspection, the practice was rated as good for providing caring and responsive services.

At this inspection, the practice was rated as requires improvement for providing well-led services because:

• We found the practice had implemented a number of structures and systems since the previous inspection. We identified that these systems required further time to fully embed and evidence that improvements had been sustained.
• We found the practice had not made improvements to all of the areas of concerns noted in our previous inspection report; for example, in relation to training.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

The areas where the provider should make improvements are:

• Continue with the planned programme of medicine reviews to undertake overdue reviews in a timely manner and ensure that review prompts are removed from patient records that no longer require them.
• Continue to develop the practice’s programme of clinical and non-clinical audit to monitor and improve the quality of care offered to patients.
• Continue to improve uptake to cervical, breast and bowel cancer screening.
• Continue to address higher than average rates of exception reporting.
• Continue to develop and encourage patient participation and feedback at the practice.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care

We carried out a comprehensive inspection of Westwood Clinic on 13 December 2018. The practice was rated as inadequate overall with ratings of inadequate for providing safe and well led services, requires improvement for providing effective and caring services and good for providing responsive services. As a result of the findings on the day of the inspection the practice was issued with a warning notice for Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance).

We carried out a comprehensive inspection of Westwood Clinic on 9 July 2019. The practice was rated as inadequate overall with ratings of inadequate for providing safe, effective, and well led services, requires improvement for caring services and good for responsive services. Following our announced comprehensive inspection on 9 July 2019, we took urgent action to suspend Westwood Clinic’s CQC registration and prevent the provider from delivering regulated activities. During the period of suspension, a caretaking practice was put in place by the local clinical commissioning group and NHS England to ensure delivery of services for patients and to implement improvements.

You can read our findings from our all of our previous inspections by selecting the ‘all reports’ link for Westwood Clinic on our website at .

This inspection was an announced focused inspection to review in detail the actions taken by the practice during the suspension period to improve the quality of care.

At this inspection we found:

• The practice had started to implement new systems and processes and improve others, to ensure the care provided was safe and effective. However, these systems needed to be fully embedded.
• The practice had taken action for the most recent safety alerts and had also actioned historic safety alerts which had previously not been managed appropriately.
• The practice planned to review all patients on a repeat medicine and prioritised those over 75, under 5 and those diagnosed with a long-term condition. At the time of inspection, the practice had completed 470 of approximately 3,200 medicine reviews.
• The practice had started to implement a system of support and review for clinicians. After each clinical session, time was blocked out for the lead GP to support members of the clinical team.
• The practice had not rectified coding issues and a six-year-old child remained incorrectly coded as having a diagnosis of Chronic Obstructive Pulmonary Disease (COPD).
• The practice had started to engage external partners in multidisciplinary team meetings.
• The practice had a visit by Cambridgeshire Fire & Rescue Service and a review of the building fire safety arrangements and the previous risk assessment found the practice to be compliant.
• The practice had started a series of patient surveys to gauge patient satisfaction on the areas for improvement identified from previous National GP patient surveys.

Following our announced comprehensive inspection, we lifted the suspension of Westwood Clinic’s CQC registration which allowed the Provider to deliver regulated activities. This service remains in special measures.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires Improvement

Are services responsive? – Good

Are services well-led? – Inadequate

We carried out a comprehensive inspection of Westwood Clinic on 13 December 2018. The practice was rated as inadequate overall with ratings of inadequate for providing safe and well led services, requires improvement for effective and for caring services and good for providing responsive services. As a result of the findings on the day of the inspection the practice was issued with a warning notice for Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance).

This inspection was an announced comprehensive inspection. This inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting legal requirements.

At the previous inspection, the practice was rated as inadequate for providing safe services. At this inspection, the practice was rated as inadequate for providing safe services because:

• We found the practice’s system for managing patient and drug safety alerts was ineffective. We found the practice had not actioned two alerts, one of which affected two patients. There was no evidence to show the practice had taken action to protect those patients from avoidable harm.
• The practice’s system for ensuring patients had a structured and comprehensive medicine review was not effective. We found 63% of eligible patients had not had a review within the previous 12 months and 58% of patients had not had a review within the previous 18 months.
• The practice did not have a system for ensuring prescribing by non-medical prescribers was appropriate or safe.
• We found a non-prescribing member of staff had made changes to patients’ prescribed medicines. However, there was no documented evidence of discussions with or approvals from a GP.
• We reviewed consultation records and found the documentation was brief and lacking detail. Observations had been manually typed into the clinical systems so alerts such as sepsis would not automatically be triggered.
• The practice’s safeguarding processes and systems were ineffective. We found that patients with safeguarding concerns did not have appropriate indicators or alerts on their records.
• We found the practice did not have oversight of the progress of actions arising from a fire risk assessment.
• The process for recording, investigating and learning from significant events was not effective. This was raised as a concern at our December 2018 inspection visit.

At the previous inspection, the practice was rated as requires improvement for providing effective services. At this inspection, the practice was rated as inadequate for providing effective services because:

• We found patients were not receiving full assessments of their clinical needs and patient care was not regularly reviewed and updated. We reviewed consultation records and found the documentation was brief and lacking detail.
• The practice’s Quality Outcomes Framework (QOF) performance evidenced a higher than average exception reporting rate. We raised this as a concern during the previous inspection visit in December 2018, however the practice had taken no actions to improve this and submitted but unverified data for 2018/2019 evidenced the high exception reporting rate had been sustained.
• The practice’s uptake of cervical, breast and bowel cancer screening was lower than the CCG and England averages. We raised this as a concern during the previous inspection visit in December 2018, however the practice had taken no actions to improve this.
• The practice’s recall system was not effective. We found a large number of patients were overdue a medicine review and Quality Outcomes Framework data showed that not all patients received a review of their conditions, demonstrated through higher than average exception reporting rates and lower than average performance for some clinical indicators.
• The practice did not have a system in place for monitoring the competence of clinical staff employed. We found examples where a clinician’s consultations were not completed or recorded in line with NICE guidelines and this had not been identified by the practice.

At the previous inspection, the practice was rated as requires improvement for providing caring services. At this inspection, the practice was rated as requires improvement for providing caring services because:

• The practice was aware of lower than average GP Patient Survey data however the practice had not taken or planned any action to address this.
• Patients we spoke with and some CQC comment cards received on the day of the inspection contained negative feedback in relation to the attitude of some clinicians at the practice. This was reflected by some complaints received by the practice. The practice had not taken or planned any action to address this.
• The practice had identified 37 carers and supported them, only 0.7% of the practice population.

At the previous inspection, the practice was rated as good for providing responsive services. At this inspection, the practice was rated as good for providing responsive services.

• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

At the previous inspection, the practice was rated as inadequate for providing well-led services. At this inspection, the practice was rated as inadequate for providing well-led services because:

• We found the practice had not made improvements to address all the concerns noted in our previous inspection report and we identified a number of new concerns.
• We found a lack of leadership capacity and capability to successfully manage challenges and identify, implement and sustain improvements.
• The practice could not evidence that risks, issues and performance were managed to ensure the safety and quality of services.
• The practice did not always involve the public, staff and external partners to sustain high quality and sustainable care. For example, the practice did not act on negative patient survey data or patient feedback and there was no active patient participation group.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Review and improve the process for recording, managing and learning from complaints.
• Review and improve the number of carers identified and supported.

Following our announced comprehensive inspection, we took urgent action to suspend Westwood Clinic’s CQC registration which prevents the Provider from delivering regulated activities.

I am keeping this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

This practice is rated as Inadequate overall. At the previous inspection in August 2015 the

practice were rated as good overall.

The key questions at this inspection are rated as:

Are services safe? – Inadequate

Are services effective? – Requires Improvement

Are services caring? – Requires Improvement

Are services responsive? – Good

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at Westwood Clinic on 13 December 2018 as part of our inspection programme.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We concluded that:

• Patients were able to access care and treatment in a timely way.
• Quality Outcomes Framework data was generally in line, or above, local and national averages. However, exception reporting data was higher than both the CCG and England averages in indicators such as mental health and diabetes.
• Complaints were dealt with appropriately; however verbal compalints were not recorded.
• In August 2018, the practice had identified staff were unclear about the reporting of significant events and introduced a new policy and guidance for staff. The practice was able to evidence an increase in the number of significant events reported, investigated and learning distributed which would have previously been missed.

However, we also found that:

• People were not adequately protected from avoidable harm.
• The leadership, governance and culture of the practice did not assure the delivery of high quality care.
• Some legal requirements were not met.

We rated the practice as inadequate for providing safe services because:

• The practice did not have an effective system in place to manage and monitor patients taking high-risk medicines.
• The practice did not have a fire risk assessment at the time of inspection.
• Recruitment checks were not always completed.
• The practice could not evidence all staff had received appropriate safety training. The practice provided a training matrix following the inspection which did not evidence staff had received all safety training relevant to their role.
• Equipment calibration was not always completed.

We rated the practice as requires improvement for providing effective services because:

• The practice’s exception reporting rate for diabetes and mental health indicators was higher than the CCG and England averages.
• The number of patients attending for cervical screening was lower than both the CCG and England averages. The practice were aware but had no actions in place to address this.
• The number of patients attending for bowel cancer screening was lower than both the CCG and England averages. The practice were aware but had no actions in place to address this.
• We were unable to ascertain how the practice reviewed the competency of staff involved in advanced clinical practice and the practice did not provide us with evidence that any staff received appraisals.

We rated the practice as requires improvement for providing caring services because:

• The practice were aware of lower than average GP Patient Survey data however the practice had no actions taking place or being planned for the future in order to address this.

We rated the practice as good for providing responsive services.

We rated the practice as inadequate for providing well led services because:

• Practice staff reported leaders were not visible and approachable, this was evident on the day of our inspection.
• Some staff we spoke with told us they felt unsupported and under-valued by the practice partners.
• Comprehensive assurance systems were not in place, for example, not all building risk assessments were not completed and a lack of management for patients on high risk medicines.
• The practice could not evidence that risks, issues and performance were managed.
• The practice did not always involve the public, staff and external partners to sustain high quality and sustainable care. For example, the practice did not act on negative patient survey data and there was no active patient participation group.
• We found the governance systems and the oversight of the management did not ensure that the practice had complete oversight of staff training and not all staff received annual appraisals.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Review and improve the process for recording all complaints to ensure verbal complaints are included.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice