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Review carried out on 9 September 2021

During a monthly review of our data

We carried out a review of the data available to us about Warley Road Surgery on 9 September 2021. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Warley Road Surgery, you can give feedback on this service.

Inspection carried out on 8 October 2019

During an inspection looking at part of the service

We carried out an announced focussed inspection at Warley Road surgery on 8 October 2019 as part of our inspection programme.

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

This inspection focused on the following key questions: Effective and Well-led.

Because of the assurance received from our review of information we carried forward the rating for the following key questions: Safe, Caring and Responsive.

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 have rated this practice as good overall and good for all population groups, except for Families, children and young people and Working age people (including those recently retired and students) which were rated as Requires Improvement.

We found that:

  • The practice had reviewed their system of managing safety alerts to ensure the appropriate actions were taken.
  • Systems had been implemented to ensure emergency equipment was regularly checked.
  • To increase the uptake of bowel cancer screening, the practice telephoned patients and spoke with them in their first language to encourage them to attend appointments.
  • The practice monitored vulnerable patients to reduce avoidable admissions.
  • National GP patient survey results were higher than average for a number of questions. The results were reviewed and discussed at team meetings.
  • The staff were aware of the difficulties of maintaining confidentiality at the reception desk and did their upmost to ensure conversations could not be overheard.
  • The practice continually reviewed the effectiveness of their services and had implemented a range of initiatives to support patients in the community.

  • Learning was encouraged and staff were given opportunities to develop the skills required for their roles and responsibilities.
  • The culture of the practice and the way it was led and managed drove the delivery and improvement of high-quality, person-centred care.
  • There was continuous commitment to patients and external stakeholders to share information, ideas and improvements. This included supporting in house advice groups to support patients in the management of their conditions.

Whilst we found no breaches of regulations, the provider should:

  • Continue to encourage patients to attend cancer screening.
  • Review current system for the monitoring of Patient Group Directions to ensure they are up to date.
  • Continue to monitor childhood immunisations to ensure targets are being met.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 3 June, 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Warley Road Surgery on 3 June 2016. Overall the practice is rated as Good.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the Care Quality Commission (CQC) at that time.

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns. Information about safety was recorded, monitored, reviewed and addressed.
  • Most risks to patients and staff were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Patients said they were treated with 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.
  • Patients told us they found difficulties getting pre-booked appointments and the appointment system was under review. Urgent appointments were 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, patients and third party organisations, which it acted on.

We saw a number of areas where the practice should make improvements.

The practice should:

  • Review the system for managing alerts received to include confirmation that appropriate actions have been taken.
  • Ensure all emergency equipment is regularly checked.
  • Consider how attendance of bowel cancer screening could be promoted to patients to improve the uptake.
  • Continue to monitor the avoidable admissions and target a reduction to bring the practice into line with local and national averages.
  • Review the patient survey results for aspects of care and consider how improvements could be made.
  • Explore ways to prevent confidentiality being compromised by conversations being overheard.

We saw one outstanding features:

  • The practice had taken steps to address the large number of patients on the list with reading and writing difficulties, for example, the clinicians checked and identified patient’s literacy and the receptionists supported patients with the completion of forms.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice