The Care Quality Commission
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  • GP practice

Archived: The Westwood Surgery

Overall: Good read more about inspection ratings

24 Westwood Lane, Welling, Kent, DA16 2HE (020) 8303 5353

Provided and run by:
The Westwood Surgery

Important: The provider of this service changed. See new profile

All Inspections

18 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

The Westwood Surgery was placed in special measures following a previous inspection.  An announced comprehensive inspection was carried out on 28 July 2015 resulting in an overall rating of Inadequate. The ratings from the  inspection for the safe, effective and well-led domains were Inadequate and for the responsive domain the rating was Requires Improvement. The provider was rated Good for the caring domain. The report for the inspection was published on 15 October 2015. Practices placed in special measures are inspected again six months after publication of the report to check whether the provider has made sufficient improvements to show they are meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The areas of concern identified from the previous inspection on 28 July 2015 were:

  • Systems, processes and practices did not keep people safe: Over 1200 documents consisting of patient related letters from hospitals and other third parties had not been actioned since October 2014 and the practice had failed to identify this as a risk.

  • A member of staff had been recruited to assist with the handling of patient related letters. This member of staff was non-clinical but was making clinical decisions. Recruitment checks had not been carried out on this member of staff.

  • Governance arrangements were unclear and the practice leadership had failed to identify and manage significant issues that threatened the delivery of safe and effective care.

  • There was little evidence that learning from events was shared with all relevant staff in order to improve safety.

We then carried out a follow up announced comprehensive inspection of  the practice on 18 May 2016. We saw evidence during this inspection that previous concerns had been addressed satisfactorily by the provider and that appropriate systems, processes and practices were now in place. 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 the reporting and recording of significant events. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.

  • Risks to patients were assessed and well managed. Clinical staff told us they received patient safety alerts such as those from Medicines and Healthcare Products Regulatory Agency (MHRA) via email but there was no system in place to monitor and record that all relevant staff had been informed and appropriate action taken where required.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. However, data showed that outcomes for patients with asthma were significantly lower than the CCG and national average.
  • Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

  • Feedback from patients about their care was consistently positive. 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 and 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.
  • The practice had a clear vision and leadership structure which had quality and safety as its top priority. The strategy to deliver this vision had been produced and discussed with staff and other stakeholders and was monitored and reviewed.
  • Staff felt supported by management and the provider proactively sought feedback from staff and patients which it acted on.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from staff, patients and the patient participation group.
  • The practice had strong and visible clinical and managerial leadership and governance arrangements.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvements are:

  • The provider should take action in response to patient feedback regarding the lack of available non-urgent appointments.

  • The provider should monitor the practice procedure to ensure that all staff are aware of MHRA alerts and have taken action where appropriate.
  • The provider should complete all outstanding tasks identified in the Legionella assessment action plan (April 2015).

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

28 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Westwood Surgery and the branch surgery; Pickford  Surgery on 28 July 2015. Overall the practice is rated as Inadequate.

Specifically, we found the practice to be inadequate for providing safe, effective and well-led services. It was requires improvement for providing responsive services and rated as good for providing a caring service.

The concerns which led to a rating of inadequate in safe, effective and well-led apply to all population groups using the practice. Therefore, all population groups have been rated as inadequate.

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

  • Systems, processes and practices did not keep people safe. As a result, patients were at risk of harm. Over 1200 documents consisting of patient related letters from hospitals and other third parties had not been actioned since October 2014 and the practice had failed to identify this risk.
  • Though staff understood their responsibilities to raise concerns, and report incidents and near misses, there was little evidence that learning from events was shared with all relevant staff in order to improve safety.
  • Staff did not assess, monitor or manage risks to people who use the service and people received care from inappropriately qualified staff. One of the GP partners had recruited a member of staff to assist them with handling their patient related letters. This member of staff was non-clinical, but was making clinical decisions. The other partners were aware of this arrangement and they had failed to recognise the risk associated with it. Furthermore, recruitment checks had not been carried out on this member of staff.
  • The governance arrangements were unclear and the practice leadership had failed to identify and manage significant issues that threatened the delivery of safe and effective care.
  • Patients said they found it easy to make an appointment with a named GP and that 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.
  • The practice proactively sought feedback from staff and patients, which it acted on.

The areas where the provider must make improvements are:

  • Ensure that only  clinical staff are involved in clinical decision making and triaging patient letters.
  • Ensure reliable and effective systems are in place for the safe management of patient related letters from hospitals and other providers.
  • Ensure learning from incidents is shared with all relevant staff.
  • Ensure learning identified from complaints is implemented effectively.
  • Ensure recruitment arrangements include all necessary employment checks for all staff.

In addition the provider should:

  • Ensure good systems are in use for the safe management of prescription pads.
  • Ensure they improve systems of handling patient feedback and complaints.
  • Ensure availability of an automated external defibrillator (AED) or undertake a risk assessment if a decision is made to not have an AED on-site.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The practice will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice