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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.

Reports


Inspection carried out on 18 & 25 October 2019

During a routine inspection

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 carried out on 13 June 2019

During an inspection to make sure that the improvements required had been made

We carried out an announced comprehensive inspection at Westway Surgery on 13 June 2019. The practice was previously inspected on 8 January 2019. Following this inspection, the practice was rated Inadequate overall and in safe, effective and well-led domains and placed in special measures. We issued warning notices for breaches of Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance). The practice was required to address these concerns by 15 May 2019.

We did not review the ratings awarded to this practice at this 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.

We found the provider had not made sufficient improvements in providing safe services regarding:

  • The provider did not have an effective system in place to safely manage patients who had been prescribed high-risk medicines.
  • The provider did not have an effective system to safely manage infection prevention and control (IPC) practices.

We found the provider had improved some systems to keep patients safe regarding:

  • The practice had improved its systems for the management of emergency medicines.
  • Receptionists have undertaken training and given guidance on identifying red flag signs for deteriorating or acutely unwell patients.

We found the provider had made some improvements for providing effective services regarding:

  • The provider had improved its systems and processes regarding clinical governance and had adhered to national guidelines.
  • The provider had increased their clinical capacity, by two GP sessions each week and by one session each week for the practice nurse, to meet patient demand for appointments.
  • The provider had undertaken a comprehensive schedule of regular training for all staff since our inspection on 8 January 2019.

However we found:

  • The provider could not demonstrate that all staff had the skills, knowledge and experience to carry out their roles.

We found the provider had improved in providing well-led services because:

  • The practice had a clear vision, that was supported by a credible strategy.
  • The practice culture supported the drive to achieving good quality sustainable care.
  • The practice could demonstrate they had effective processes in place for managing risks, issues and performance.
  • The provider had improved the support available for carers.
  • The provider had improved its provision of services for patients who have additional communication needs.

The areas where the provider must make improvements are:

  • The provider must ensure and demonstrate they have systems in place to safely and effectively manage patients who have been prescribed high-risk medicines.
  • The provider must ensure and demonstrate they have systems in place to safely and effectively manage infection prevention and control (IPC) practices in line with national guidelines.
  • The provider must ensure that persons providing care or treatment to service users have the qualifications and experience to do so safely.

The service will remain in special measures until we have undertaken the next inspection and this will be reviewed at that time. This 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 carried out on 08 January 2019

During a routine inspection

We carried out an announced comprehensive inspection at Westway Surgery on 8 January 2019. The practice was previously inspected in October 2014 and was rated good overall, with requires improvement for the patient population groups of families, children and young people and people who are experiencing poor mental health (including people with dementia).

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 inadequate overall.

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

•The practice did not have clear systems and processes to keep patients safe.

•Receptionists had not been given guidance on identifying red flag signs for deteriorating or acutely unwell patients. They were not aware of actions to take in respect of such patients.

•The practice did not have appropriate systems in place for the safe management of medicines.

•The practice did not learn and make improvements when things went wrong.

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

•There was limited monitoring of the outcomes of care and treatment.

•The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.

•The practice was unable to show that it always obtained consent to care and treatment.

•Some performance data was significantly below local and national averages.

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

•The practice was unable to demonstrate effective systems and processes to keep people safe.

•There are inadequate systems and processes in place to be assured of the quality and safety of the service being provided.

•Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.

•The practice did not have a clear or credible strategy.

•The practice culture did not effectively support high quality sustainable care.

•The practice did not have clear and effective processes for managing risks, issues and performance.

•The practice did not always act on appropriate and accurate information.

•We saw no evidence of systems and processes for learning, continuous improvement and innovation.

These areas affected all population groups so we rated all population groups as inadequate.

We rated the practice as requires improvement for providing caring and responsive services because:

•The practice had limited systems in place to identify carers and provide relevant support.

•Staff dealt with patients with kindness and respect.

•Patients made positive comments about the care and treatment they received.

•Patients could generally access care and treatment in a timely way, although appointment times were limited.

The areas where the provider must make improvements are:

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

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

I am placing this service in special measures. Services 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 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 carried out on 02 and 03 October 2014

During a routine inspection

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