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We are carrying out checks at The Westway Surgery. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Good

Updated 26 March 2015

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection the 03 and 04 October 2014. We rated the practice as ‘Good’ for the service being safe, effective, caring, responsive to people’s needs and well-led. We rated the practice as ‘Good’ for the care provided to older people and people with long term conditions, working age people (including those recently retired and students), people living in vulnerable circumstances and people experiencing poor mental health (including people with dementia). We rated the practice as ‘requires improvement’ for mothers babies children and young people.

We gave the practice an overall rating of ‘Good’

Our key findings were as follows:

  • Patients reported that the Westway Surgery provided an accessible medical service from a staff team who were respectful and caring.

  • The practice had systems in place to ensure that the service was safe. Recruitment checks were carried out on staff prior to their employment at the practice. The practice was clean and infection and prevention control procedures were carried out.

  • The staff team had the opportunity to undertake training and professional development.

  • Patients’ complaints and concerns were investigated. Improvements were made as a result of the review of incidents and complaints.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

  • Offer staff training on the Mental Capacity Act, on how to ensure patients under the age of sixteen are able to make an informed decision and consent to their care if they attend the surgery without a parent or carer (Fraser Guidelines and Gillick Competency).

  • Ensure that medical equipment (for example weighing scales and blood pressure monitors) are serviced and calibrated.
  • Introduce a formal system for recording checks which have been made on cleaning at the practice.

  • Develop a long term plan and team improvement objectives to monitor performance.
  • Ensure all staff meetings are formally recorded.

  • Ensure a business continuity plan is in place.

  • Offer staff training on the Mental Capacity Act, on how to ensure patients under the age of sixteen are able to make an informed decision and consent to their care if they attend the surgery without a parent or carer (Fraser Guidelines and Gillick Competency).

  • Ensure that medical equipment (for example weighing scales and blood pressure monitors) are serviced and calibrated.
  • Introduce a formal system for recording checks which have been made on cleaning at the practice.

  • Develop a long term plan and team improvement objectives to monitor performance.
  • Ensure all staff meetings are formally recorded.

  • Ensure a business continuity plan is in place.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 26 March 2015

The practice is rated as good for providing safe services. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Lessons were learned and communicated widely to support improvement. Information about safety was recorded, monitored, appropriately reviewed and addressed. Systems were in place for infection control and health and safety. There was a cleaning schedule for the practice but periodic monitoring checks of cleaning standards were not recorded.

Risks to patients were assessed and well managed. There were enough staff to keep people safe.

Effective

Good

Updated 26 March 2015

The practice is rated as good for providing effective services. Data showed patient outcomes were at or above average for the locality. Staff referred to guidance from NICE and used it routinely. People’s needs were assessed and care was planned and delivered in line with current legislation. The awareness of the need to assess the capacity of some patients to make an informed choice and consent to their treatment was not evident. For example the use of the Mental Capacity Act 2005 and Gillick Competency for patients under the age of sixteen.

Staff had received training appropriate to their roles and any further training needs have been identified and planned. The practice could identify all appraisals and the personal development plans for all staff. Staff worked with multidisciplinary teams.

Caring

Good

Updated 26 March 2015

The practice is rated as good for providing caring services. Data showed that patients rated the practice higher than others for several aspects of care. Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. Information to help patients understand the services available was easy to understand.

Responsive

Good

Updated 26 March 2015

The practice is rated as good for providing responsive services. It reviewed the needs of its local population and engaged with the NHS Area Team and Clinical Commissioning Group (CCG) to secure improvements to services where these were identified.

The information we received from patients told us the appointments system was accessible and patients were generally able to make an appointment when they needed one. Where there was a difficulty in making an appointment, patients said that reception staff ensured a time for a consultation was eventually identified.

The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand and evidence showed that the practice responded quickly to issues raised. There was evidence of shared learning from complaints with staff and other stakeholders.

Well-led

Good

Updated 26 March 2015

The practice is rated as good for being well-led. It had a clear vision and strategy. Staff were clear about the vision and their responsibilities in relation to this. However, a formal process was not in place to set improvement goals for the practice, and to monitor the performance of the practice against these goals.

There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings. There were systems in place to monitor and improve quality and identify risk. The practice sought feedback from staff and patients, which it acted on. The patient participation group (PPG) was active. Staff had received inductions, regular performance reviews and attended staff meetings and events.

Checks on specific services

People with long term conditions

Good

Updated 26 March 2015

The practice is rated as good for the care of people with long-term conditions. There were emergency processes in place and referrals were made for patients whose health deteriorated suddenly. Home visits were available when needed. All these patients had a named GP and a structured annual review to check that their health needs were being met. For those people with the most complex needs, the GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

The practice nurse supported patients with long term conditions, for example patients with diabetes and asthma. A high proportion of patients were treated for diabetes and we were informed that health education was part of this treatment. Patients who have asthma were referred to the community respiratory unit for their care and treatment.

Families, children and young people

Requires improvement

Updated 26 March 2015

The practice is rated as requires improvement for the care of families, children and young people. Childhood immunisation rates were mixed with the uptake of some childhood vaccinations being above the CCG average and the uptake of other childhood immunisations being below the CCG average.

In discussion with some clinical staff it was apparent Gillick competency and Fraser Guidelines were not always incorporated into practice, as staff told us that a request was made for patients under the age of sixteen to attend their appointment with an adult who would then give consent on behalf of the young person.

Families with babies and young children were able to make an appointment with the practice nurse for child hood immunisations. Staff were aware of child protection procedures and knew how to escalate possible concerns to the designated safeguarding lead at the practice. There was guidance for all staff on how to refer concerns about children to the child protection team (Social Services).

Appointments were available outside of school hours and the premises were suitable for children and babies.

Older people

Good

Updated 26 March 2015

The practice is rated as good for the care of older people. Nationally reported data showed that outcomes for patients were good for conditions commonly found in older people. The practice offered care to meet the needs of the older people in its population and had a range of enhanced services, for example, in dementia and end of life care. It was responsive to the needs of older people, and offered home visits for housebound patients.

Working age people (including those recently retired and students)

Good

Updated 26 March 2015

The practice is rated as good for the care of working-age people (including those recently retired and students). The needs of the working age population and those recently retired had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. There was a range of health promotion and screening that reflects the needs for this age group.

People experiencing poor mental health (including people with dementia)

Requires improvement

Updated 26 March 2015

The practice is rated as requires improvement for the care of people experiencing poor mental health (including people with dementia). The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. It carried out care planning for patients with dementia.

The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations including MIND.

Staff had not received training on how to care for people with mental health who required a mental capacity assessment to ensure they were able to make an informed choice and give consent to treatment.

People whose circumstances may make them vulnerable

Good

Updated 26 March 2015

The practice is rated as good for the care of people whose circumstances may make them vulnerable. The practice held a register of patients with a learning disability. Annual checks for people with a learning disability were carried out by the practice nurse.

The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people. Vulnerable patients were made aware how to access various support groups and voluntary organisations. Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.