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Review carried out on 13 March 2020

During an annual regulatory review

We reviewed the information available to us about Western Elms Surgery on 13 March 2020. 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.

Inspection carried out on 10 January 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall.

At our previous inspection in November 2014 the practice had an overall rating as good.

Following the November 2014 inspection, the key questions were rated as:

  • Are services safe? – Good

  • Are services effective? – Good

  • Are services caring? – Good

  • Are services responsive? – Good

  • Are services well-led? – Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups were rated as:

  • Older People – Good

  • People with long-term conditions – Good

  • Families, children and young people – Good

  • Working age people (including those recently retired and students – Good

  • People whose circumstances may make them vulnerable – Good

  • People experiencing poor mental health (including people with dementia) – Good

We carried out an announced comprehensive inspection at Western Elms Surgery in Reading, Berkshire on 10th January 2018. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether Western Elms Surgery was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

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 fully engaged with programmes developed in the local area to support patient’s health and wellbeing in a number of different ways. For example, a coffee morning hosted at a local church for patients over 75 years to share health information and receive feedback.
  • 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. The practice was above average for its satisfaction scores on consultations with GPs and nurses in a number of areas.
  • Patients found the appointment system easy to use and reported that they were able to access urgent care when they needed it.
  • Services were tailored to meet the needs of individual people and delivered in a way that ensured flexibility and choice. For example, the practice operated a drop-in family planning clinic and worked collaboratively with other external organisations and charities.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • We received positive feedback from external stakeholders and patients who access GP services from the practice.

We saw one area of outstanding practice including:

  • Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information they are given): The practice had nominated a project leader and established a working group, involving representatives of the Patient Participation Group (PPG) and local healthcare charities, to survey patients and recommend improvements. For example greetings and frequently asked questions at reception had been produced in six different languages and representatives from Mencap and Healthwatch frequently attended the surgery to act as advocates for appropriate patients. Signage in the waiting room offered information in alternative formats and a protocol had been developed to help patients with hearing difficulties. All staff had received dementia awareness training and Makaton (a language programme using signs and symbols to help people communicate) training had been scheduled for a future practice training day.

The areas where the provider should make improvements are:

  • Continue to review arrangements for the identification of carers to assure the practice that they are being identified effectively and provide any support they may require.
  • Review processeses to ensure that Patient Group Directions (PGDs) are signed by appropriate members of staff.
  • Review processes for increasing the take up of children’s immunisations.
  • Continue to prioritise patients on the Learning Disabilities register and review arrangements to ensure all patients receive an annual health check. 

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 11 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Western Elms Surgery is located in a converted building in West Reading. There are approximately 16,000 patients registered at the practice. We carried out an announced comprehensive inspection of the practice on 11 November 2014. We visited Western Elms Surgery during this inspection. This was the first inspection of the practice since registration with the CQC.

The practice has had significant changes to staffing over the last two years, specifically changes in the GP partners. The patient population is very transient and this means the patient list changes a great deal over time. The practice monitors its appointment system and is aware of some concerns among patients about the ability to book non-urgent appointments. The practice responds to changes in demands by auditing its appointment system when there is concern about the demand for appointments. Patients were able to make appointments when they needed them. The premises were accessible to patients with limited mobility and all clinical areas were located on the ground floor. Patients told us staff were caring, friendly and considerate. The practice patient participation group is involved in the running of the practice and has been involved in making changes to the practice. For example, they lobbied the local authority for on street disabled parking due to the shortage of spaces at the practice and achieved their goal.

We spoke with nine patients during the inspection. We met two of the patient participation group, three GPs, the practice manager, assistant manager, three members of the nursing team and administration staff.

Western Elms Surgery practice was rated good overall.

Our key findings were as follows:

Patients were mostly positive about the care they received from GPs and nurses. All the patients we spoke with or who provided feedback told us staff were caring. Some patients were concerned about the booking appointments with their GP, saying they may have to wait up to three weeks to see them, but that they could see other GPs when they needed. All patients we spoke with said they could book an urgent appointment. The practice had systems to keep patients safe including safeguarding procedures and means of sharing information about patients who were vulnerable. Western Elms Surgery was hygienic and infection control was monitored. The practice was well maintained and equipment was serviced. There was strong strategic leadership and a positive culture which encouraged learning and openness.

We saw one area of outstanding practice including:

  • The practice had implemented an IT tool which assisted the practice in identifying patients at risk of unplanned admissions and 45 vulnerable patients per GP had been identified as requiring a care plan.

However, there were also areas of practice where the provider should make improvements.

The provider should:

  • ensure nursing staff have an appropriate understanding of the Mental Capacity Act 2005.

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Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice