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Inspection carried out on 14 January 2020

During an inspection looking at part of the service

We carried out an announced focused inspection at Weston Lane Surgery on 14 January 2020 as part of our inspection programme.

At this inspection we followed up on the breach to regulation 12 of the Health and Social Care Act 2014: Safe Care and treatment identified at a previous inspection on 25 February 2019. The shortfalls identified related a lack of assurance around safe management of medicines and in the following of the policies and procedures for managing, administering and storing of medicines. We also identified some areas for improvement around fire safety across the main location and branch sites (although these were not part of the regulatory breach).

In December 2019 we undertook an annual regulatory review for Weston Lane Surgery and from this we identified there had been no change to the quality of care for delivering effective, caring, responsive or well-led services. As such we undertook a planned follow up inspection of safe only to follow up on the regulatory breaches identified at the previous inspection.

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.

The practice is now rated as good for safe.

We found that:

  • The practice had made improvements to the areas identified in breach of regulation at the previous inspection particularly for cold chain storage.
  • The practice had streamlined their fire safety policies and processes across each location or branch site across the organisation.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • The practice had continued to monitor staffing levels and recruit to vacant posts in order to ensure safe delivery of services.
  • The practice had implemented new systems to support with monitoring and oversight of training, HR and recruitment as well as for reviewing of maintenance.

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

Review carried out on 28 November 2019

During an annual regulatory review

We reviewed the information available to us about Weston Lane Surgery on 28 November 2019. 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 25 February 2019

During a routine inspection

We carried out an announced comprehensive inspection at The Living Well Partnership on 25, 26, 27 February 2019 as part of our inspection programme.

This practice as Weston Lane Surgery had been previously inspected in January 2016.

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.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm, with the exception of medicines requiring refrigeration.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a consistently safe way.

In addition, the provider should:

  • Review the fire procedures across all branches to ensure that there is consistency and continuity. Ensuring fire evacuation procedures are accessible to staff at all sites.
  • Review exception reporting rates for patients with long term conditions.
  • Continue to review patient feedback to ensure services meet patients’ needs.
  • Continue to improve patient access to appointments and telephone contact.

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 19 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Weston Lane Surgery on Wednesday 19 October 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 for reporting and recording significant events.
  • 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 provider was aware of and complied with the requirements of the duty of candour.
  • The practice was actively involved in the community it served and supported patients to access other organisations. It was developing its own model that was working to create an environment that could respond and manage the continuously changing needs of its patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice