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The Westway Surgery Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 February 2021

The Westway Surgery is a GP provider registered with CQC.

  • Following a comprehensive inspection on 8 January 2019, we rated the practice inadequate overall and in the safe, effective and well-led key questions and across all population groups. Caring and responsive key questions were rated requires improvement. The practice was placed in special measures and issued warning notices for breaches of Regulation 12 (safe care and treatment) and 17 (good governance) of the Health and Social Care (HSCA) 2008 (Regulated Activities) Regulations 2014.

  • We carried out an announced follow-up inspection at the practice on 13 June 2019 to check compliance with the warning notices. We did not review the ratings awarded to the practice at this inspection. Following the inspection we issued a further warning notice for breaches of Regulation 12 of the HSCA 2008 (Regulated Activities) Regulations 2014 and the practice remained in special measures.

  • We carried out announced comprehensive inspections at the practice on 18 and 25 October 2019 as part of our inspection programme. This inspection was a six month review of special measures. We rated the practice as requires improvement overall and in the responsive and well-led key questions and four of the population groups (older people, long term conditions, vulnerable people, people experiencing poor mental health). The safe and caring key questions were rated good. This practice remained in special measures because it retained a rating of inadequate for the effective key question and the remaining two population groups (families, children and young people, and working age people). We issued a requirement notice for breaches of Regulation 17 of the HSCA 2008 (Regulated Activities) Regulations 2014.

The report of the previous inspections can be found by selecting the 'all reports' link for The Westway Surgery on our website at www.cqc.org.uk.

We carried out this comprehensive inspection of the practice on 7 December 2020. Following this inspection, we rated the practice requires improvement overall. The safe, effective and well-led key questions were rated requires improvement along with two population groups (families, children and young people, and working age people). The caring and responsive key questions were rated good along with the remaining four population groups.

We also remotely reviewed specific documentation including policies and audits. (In light of the current Covid-19, CQC has looked at ways to fulfil our regulatory obligations, respond to risk and reduce the burden placed on practices by minimising the time inspection teams spend on site. In order to seek assurances around potential risks to patients, we are currently piloting a process of remote working as far as practicable. This provider consented to take part in this pilot and some of the evidence in the report was gathered without entering the practice premises).

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 providers, patients, the public and other organisations

We rated the practice requires improvement for providing safe services because:

  • We found concerns in relation to the monitoring of patients taking a high risk medicine, the effectiveness of the monitoring system for people on direct oral anticoagulants (DOACs) and compliance with safety alerts.

We rated the practice requires improvement for providing effective services because:

  • Although there was some improvement since the last inspection, cervical screening and childhood immunisation achievement rates remained below national targets.

We rated the practice good for providing caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The latest published national GP patient survey results for caring indicators was in line with or above CCG and England averages.

We rated the practice good for providing responsive services because:

  • The practice had improved access to appointments with clinical staff on Thursday mornings.
  • The latest published national GP patient survey results for responsive indicators was generally in line with or above CCG and England averages.

We rated the practice requires improvement for providing well-led services because:

  • Despite significant concerns being identified at previous inspections, the required improvements had not been sufficiently embedded or sustained as we found new concerns relating to medicines management and shortfalls in the monitoring of safety alerts.
  • Although improvement plans had been implemented to improve the uptake of childhood immunisations and cancer screening, achievement rates remained below national targets.

The areas where the practice must make improvements are:

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

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

The areas where the practice should make improvements are:

  • Work to improve the systems and processes to increase childhood immunisations and cancer screening uptake.
  • Review outstanding actions from all health and safety risk assessments.
  • Work to improve early morning access to GP appointments.

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

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

Safe

Requires improvement

Effective

Requires improvement

Caring

Good

Responsive

Good

Well-led

Requires improvement
Checks on specific services

People with long term conditions

Good

Families, children and young people

Requires improvement

Older people

Good

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good