Archived: West End Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at West End Surgery on 25 March 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe, effective and well-led services. It was good for providing a caring, and responsive service. It also required improvement for providing services for all six of the population groups we inspected, based on the findings in the overall domains.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were not always assessed or well managed, specifically those relating to recruitment checks and infection prevention and control.
• Data showed patient outcomes were average for the locality. Although some audits had been carried out, we saw limited evidence that audits were driving improvement in performance to improve patient outcomes.
• Patients said they were treated with compassion, dignity and respect.
• Information about services and how to complain was available and easy to understand.
• Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait a long time for non-urgent appointments.
• The practice had not proactively sought feedback from staff or patients.

The areas where the provider must make improvements are:

• Ensure recruitment arrangements are robust and ensure that all employment checks are carried out before staffs starts working at the practice.
• Ensure risk assessments in place to protect patients and staff from risk of harm. Specifically in respect of infection prevention and control. Additionally infection control audits should be carried out and their findings acted on.
• Ensure there are formal governance and management arrangements in place and staff are aware how these operate. For example policies, procedures and guidance to carry out their role and that feedback from staff and patients is responded to.

In addition the provider should:

• Consider how to improve the availability of non-urgent appointments.
• Keep records of equipment checks for defibrillator and emergency medicines

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice