The Care Quality Commission
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Archived: Bridgewater CHCFT The Willaston Surgery

Overall: Good read more about inspection ratings

Neston Road, Willaston, Neston, Merseyside, CH64 2TN (0151) 327 4593

Provided and run by:
Bridgewater Community Healthcare NHS Foundation Trust

Important: This service is now managed by a different provider - see new profile
Important: The provider of this service changed. See old profile

All Inspections

19 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Bridgewater CHCFT The Willaston Surgery on 24 August 2016. The overall rating for the practice was Good. The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for Bridgewater CHCFT The Willaston Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 19 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 24 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated as Good.

Our key findings were as follows:

  • The provider had ensured the premises were safely maintained. Evidence of a satisfactory electrical wiring inspection had been made available.

The following improvements to the service had also been made:

  • Evidence was provided to demonstrate that significant events were reviewed at practice level to enable patterns and trends to be identified and any appropriate action to be carried out.

  • Further improvements had been made to the system for ensuring adult patients with depression were receiving a review at the recommended frequencies following a new diagnosis.

  • A plan had been put in place to ensure all staff received training in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

  • The induction records for clinical and non-clinical staff and the GP locum pack had been reviewed to provide greater detail and to ensure staff were provided with the information they needed.

  • The protocol for incoming correspondence had been reviewed to ensure clarity of what should be sent to the GPs for review and action.

  • A planned programme of audits had been put in place.

  • Information about how patients can make a complaint had been revised to include who complaints should be directed to at the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

24th August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bridgewater CHCFT The Willaston Surgery on 24 August 2016.

Overall the practice is rated as good.

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

  • There were systems in place to reduce risks to patient safety, for example, infection control procedures, medication management and the management of staffing levels. Evidence that the electric wiring installation for the premises was safe was not in place.
  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Staff were aware of procedures for safeguarding patients from the risk of abuse.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Staff felt well supported. They received training appropriate for their roles and an appraisal every 12 months.
  • Patients were positive about the care and treatment they received from the practice. The National Patient Survey January 2016 showed that patients’ responses about whether they were treated with respect, compassion and involved in decisions about their care and treatment were comparable to local and national averages.
  • Services were planned and delivered to take into account the needs of different patient groups.

  • The National GP Patient Survey results showed that patient’s satisfaction with access to care and treatment was in line with or above local and national averages.

  • Information about how to complain was available. There was a system in place to manage complaints.
  • There were systems in place to monitor and improve quality and identify risk.

However there were areas of practice where the provider must make improvements:

  • Ensure that the electrical wiring at the premises is safe.

The areas where the provider should make improvements are:

  • Undertake a periodic analysis of significant events at a practice level to enable patterns and trends to be identified and any appropriate action carried out.

  • Continue to improve the system for monitoring that adult patients with depression were receiving a review at the recommended frequencies following a new diagnosis.

  • All staff should receive training in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

  • The induction records for clinical and non-clinical staff and the GP locum pack should provide greater detail to ensure staff are provided with the information they need.

  • Review the protocol for incoming correspondence for clarity of what should be sent to the GPs for review and action.

  • A planned programme of audits should be put in place.

  • Information about how patients can make a complaint should include the contact details of NHS England and who complaints should be directed to at the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice