Background to this inspection
Updated
11 February 2020
West Street Surgery provides a range of primary medical services, including minor surgical procedures, from its location at 89 West Street, Dunstable, Bedfordshire, LU6 1SF. It is part of the NHS Bedfordshire Clinical Commissioning Group (CCG). The practice holds a General Medical Services contract (GMS), this is a nationally agreed contract with NHS England.
The practice serves a population of approximately 12,000 patients with a slightly higher than national average population of patients aged over 65 years and slightly lower than national average population of patients aged between five and 14 years. The practice population is 92% white British.
The practice supports five local care homes and one home for people with a learning disability.
Information published by Public Health England rates the level of deprivation within the practice population group as seven on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.
The clinical team consists of two male and one female GP partners, two female salaried GPs and one female long-term locum GP. The practice also employs three female senior nurse practitioner prescribers, three female practice nurses. One practice nurse provides home visits to patients unable to attend the practice. The clinical team also includes a health care assistant, a phlebotomist and a practice-based pharmacist. The team is supported by a practice manager and a team of non-clinical, administrative staff. Members of the community midwife team and a mental health link worker operate regular clinics from the practice.
The practice operates from a two-storey purpose-built property, with disabled access throughout. Patient consultations and treatments take place on the ground floor level. There is a large car park outside the surgery, with parking for people living with disabilities available.
West Street Surgery is open from 8am to 6.30pm on Monday to Friday with extended opening on Monday and Wednesday until 7.30pm. They have recently worked with five local surgeries to provide extended access to patients. When the practice is closed, out of hours services can be accessed via the NHS 111 service. Information about this is available in the practice and on the practice website.
The practice provides family planning, surgical procedures, maternity and midwifery services, treatment of disease, disorder or injury and diagnostic and screening procedures as their regulated activities.
Updated
11 February 2020
The service is rated as Good overall.
We carried out an announced comprehensive inspection at West Street Surgery on 27 January 2020 to confirm that the practice had carried out the necessary improvements in relation to their breaches of regulation.
The practice received an overall rating of inadequate at our inspection on 20 September 2019 and 22 May 2019 and warning notices were issued.
The full comprehensive report from the September 2019 and May 2019 inspection can be found by selecting the ‘all reports’ link for West street Surgery on our website at .
Our judgement of the quality of care at this service is based 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.
The practice is rated a
s good overall.
(previously rated as inadequate in May 2019)
Key findings:
- The practice was compliant with the warning notices issued in May 2019.
- People who used the service were protected from avoidable harm and abuse, and requirements were met. Staff had a good understanding of how to escalate concerns.
- There was effective audits and risk assessments in place in relation to fire, legionella, health and safety and infection prevention and control. Actions required were being completed.
- There was effective management of medicines and prescribing including for medicines that required additional monitoring.
- There was good oversight of pathology results and clinical practice. The practice had conducted clinical competency assessments and mentoring sessions that fed into individual appraisals.
- Patients had good outcomes because they received effective care and treatment that met their needs.
- Patients were supported, treated with dignity and respect and were involved as partners in their care.
- Patients’ needs were met by the way in which services were organised and delivered.
- Concerns raised regarding access to the practice via the telephone were being addressed by the introduction of an improved telephone system.
- The practice delivered person-centred care and communicated effectively with community teams. They were flexible to the needs of the most vulnerable and complex patients.
- The leadership, governance and culture of the practice promoted the delivery of high quality person-centred care.
- Regular staff meetings were held to ensure communication was clear and effective.
- Staff were proud to work at the practice and were supported with their personal and professional development.
The area where the provider should make improvements are:
- Continue to monitor and improve child immunisation uptake.
- Continue to monitor and cancer screening and care planning uptake.
- Continue to monitor and improve levels of patient satisfaction regarding lower than average indicators.
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 BS BM BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care