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The Westway Surgery Requires improvement

We are carrying out a review of quality at The Westway Surgery. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 7 January 2020

We carried out an announced comprehensive inspection at The Westway Surgery on 18 & 25 October 2019 as part of our inspection programme. We previously inspected The Westway Surgery on 8 January 2019. Following the inspection, the practice was rated inadequate overall and placed in special measures. We issued warning notices for breaches of Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance). We carried out a follow-up inspection on 13 June 2019 to check compliance with the warning notices and following the inspection we issued a further warning notice for Regulation 12 (Safe care and treatment). This inspection was a six month review of special measures.

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 requires improvement overall.

We have rated the practice as

requires improvement

for older people, people whose circumstances may make them vulnerable, people with long-term conditions and people experiencing poor mental health population groups and inadequate for families children and young people and working age population groups.

We rated the practice as Good for providing safe services because:

  • The practice had improved their systems and processes to keep patients safe.
  • The practice learnt and made improvements when things went wrong.

We rated the practice as Inadequate for providing effective services because:

  • The practice could not demonstrate how the competence of clinical staff who carried out long-term condition reviews was assured.
  • The most recent published data for childhood immunisations and cancer screening was significantly below the Clinical Commissioning Group (CCG) and England averages and performance had deteriorated since the January 2019 inspection.

We rated the practice as Good for providing caring services because:

  • Patient feedback in relation to the caring aspects of the service was consistently positive.
  • The provider had improved on the identification and support of patients with carer responsibilities.
  • The latest published national GP patient survey results for caring indicators was above CCG and England averages.

We rated the practice as Requires Improvement for providing responsive services because:

  • Although the provider had increased the practice’s opening hours and clinical sessions, routine appointments with clinical staff were restricted in the mornings which affected all the population groups..

We rated the practice as Requires Improvement for providing well-led services because:

  • The practice had no effective system to assure the competence of clinical staff who carried out long-term condition reviews.
  • The follow up system to improve quality outcomes for patients was not effective for cervical cancer screening and child immunisations.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Improve the documentation of examinations in the patient record.
  • Continue to develop quality improvement activity including clinical audit.
  • Review unplanned admissions and readmissions to monitor themes and trends.
  • Review access to appointments for all the population groups.
  • Continue to strengthen leadership and governance arrangements.
  • Implement policies and procedures for all aspects of the service provided.

This practice will remain in Special Measures because it has a rating of Inadequate for the Effective domain. The service 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 remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve

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 areas








Requires improvement


Requires improvement
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people


Older people

Requires improvement

Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement