You are here

Inspection Summary


Overall summary & rating

Good

Updated 17 January 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at West4GPS on 29 July 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. The provider was aware of and complied with the requirements of the duty of candour.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients 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 patients and meet their needs.
  • 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 areas where the practice should make improvements are:

  • The practice has a patient participation group with members who are keen to constructively contribute to the development of the practice. The practice should make more use of this resource.

  • The practice should ensure that it actively identifies patients who are also carers so they can be offered appropriate support.

  • The practice should make more information about mental health available in the waiting area.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 17 January 2017

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events.
  • Lessons were shared to make sure action was taken to improve safety in the practice.
  • When things went wrong patients received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.
  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.
  • Risks to patients were assessed and well managed.

Effective

Good

Updated 17 January 2017

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average compared to the national average.
  • Staff assessed needs and delivered care in line with current evidence based guidance.
  • Clinical audits demonstrated quality improvement.
  • 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.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 17 January 2017

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for most aspects of care.
  • Patients said they were treated with respect and they were involved in decisions about their care and treatment.
  • Information for patients about the services available was easy to understand and accessible.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Responsive

Good

Updated 17 January 2017

The practice is rated as good for providing responsive services.

  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.
  • Patients said they found it easy to make an appointment with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 17 January 2017

The practice is rated as good for being well-led.

  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.
  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.
  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
  • The provider was aware of and complied with the requirements of the duty of candour. The partners encouraged a culture of openness and honesty. The practice had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken.
  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active.
  • There was a strong focus on continuous learning and improvement at all levels.
Checks on specific services

People with long term conditions

Good

Updated 17 January 2017

The practice is rated as good for the care of people with long-term conditions.

  • The practice scored highly on the Quality and Outcomes Framework (QOF) achieving 99.9% in 2015/16.
  • The practice kept registers of patients with long term conditions. These patients had a structured annual review to check their health and medicines needs were being met.

  • The practice ran clinics for diabetes and patients receiving anticoagulant therapy.

  • The practice operated call-recall systems to encourage patients with long-term conditions to attend for their review. The practice had recently improved its system for calling diabetic patients for review.
  • Practice performance for diabetes was above average. The percentage of diabetic patients whose blood sugar levels were adequately controlled was 83% compared to the clinical commissioning group average of 74% and the national average of 78%.

  • Patients identified as at risk were reviewed and had a personalised care plan. Cases were discussed at regular multidisciplinary meetings.

Families, children and young people

Good

Updated 17 January 2017

The practice is rated as good for the care of families, children and young people.

  • There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances.

  • The practice held a weekly drop-in baby clinic. The practice had consistently achieved its targets for all standard childhood immunisations.

  • Children and young people were treated in an age-appropriate way and were recognised as individuals. The premises were suitable for children and babies.

  • Appointments were available outside of school hours.

  • The practice's emergency admission rates for patients with asthma were statistically significantly lower than the CCG average.

  • The practice was located in the same building as the health visiting team and we saw positive examples of timely communication and referral to health visitors and other community health services.

Older people

Good

Updated 17 January 2017

The practice is rated as good for the care of older people.

  • The practice offered proactive, personalised care to meet the needs of the older people in its population. Patients over 75 had been informed of their named GP.
  • The practice was responsive to the needs of older people, and offered home visits, care planning and urgent appointments for those with enhanced needs. The practice nurse and GPs carried out home visits when appropriate.
  • All patients over 65 were offered the annual flu vaccination. The practice also offered the shingles and pneumococcal vaccines to eligible older patients.
  • The practice was active in the community and responsive to its patients' needs. For example, the practice had a large number of older patients and had recently hosted a tea party to celebrate the Queen's 90th birthday.

Working age people (including those recently retired and students)

Good

Updated 17 January 2017

Working age people (including those recently retired and students)

The practice is rated as good for the care of working-age people (including those recently retired and students).

  • The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible and flexible.
  • Appointments were available until 7:45pm on two days a week. GP and nurse appointments were available in the evening.
  • The practice offered a range of ways to access services, for example, daily telephone consultations with a GP, online appointment booking and an electronic prescription service. A third of patients had signed up to the online appointment booking system.
  • The practice offered a full range of health promotion and screening services reflecting the needs for this age group.
  • 80% of eligible women registered with the practice had a recorded cervical smear result in the last five years compared to the CCG average of 78%.
  • The practice offered a range of long acting reversible contraceptives including coil fitting and contraceptive implants.

People experiencing poor mental health (including people with dementia)

Good

Updated 17 January 2017

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

  • One of the GPs took the lead for mental health within the practice.
  • 87% of patients with dementia had attended a face to face review of their care in the last year compared to the CCG average of 86%.

  • The practice participated in a scheme with the local mental health services to provide community based support to patients with mental health problems. The practice liaised with specialist teams in the case management of patients experiencing poor mental health or who showed signs of becoming unwell.

  • The practice was able to advise patients experiencing poor mental health and their carers how to access various support groups and voluntary organisations.

  • The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

  • The practice participated in a GP rota to visit patients at a local elderly mental health unit at weekends with the aim of reducing hospital admissions.

People whose circumstances may make them vulnerable

Good

Updated 17 January 2017

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

  • The practice held a register of patients living in vulnerable circumstances including people with a learning disability.

  • The practice offered longer and same day appointments for patients with a learning disability or who were otherwise vulnerable due to their circumstances.

  • The practice maintained a register of patients who were also carers. Carers were offered regular reviews and flu vaccination.

  • T

    he practice regularly worked with other health care professionals in the case management of vulnerable patients.

  • Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.