The Care Quality Commission
  • Doctor
  • GP practice

Westcroft Health Centre

Overall: Good read more about inspection ratings

1 Savill Lane, Westcroft, Milton Keynes, Buckinghamshire, MK4 4EN

Provided and run by:
Westcroft Health Centre

All Inspections

24/11/2022

During an inspection looking at part of the service

We carried out an announced inspection at Westcroft Health Centre on 24 November 2022. Overall, the practice is rated as good.

We rated each key question as follows:

Safe - Requires improvement

Effective – Good

Well-led – Good

Following our previous inspection on 27 January 2020, the practice was rated Good overall and good for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Westcroft Health Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was part of our inspection sampling programme for locations currently rated good. We carried out a focused inspection and this included a site visit. We inspected the safe, effective and well-led key questions.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included;

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit.

Our findings

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 Good overall

We found that:

  • The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse in most cases.
  • Appropriate standards of cleanliness and hygiene were not always met.
  • There were adequate systems to assess, monitor and manage risks to patient safety in most cases.
  • The practice’s systems for the appropriate and safe use of medicines, including medicines optimisation and the management of long-term conditions were not always comprehensive.
  • The practice had a system to learn and make improvements when things went wrong. However, not all safety alerts had been acted on or appropriately reviewed.
  • Patients’ needs were assessed and care and treatment was delivered in line with care pathways.
  • There was a programme of monitoring the outcomes of care and treatment.
  • The practice was able to demonstrate in most cases that staff had the skills, knowledge and experience to carry out their roles.
  • Staff worked with other organisations to deliver effective care and treatment.
  • Staff were consistent and proactive in helping patients to live healthier lives.
  • People were able to access care and treatment in a timely way.
  • The practice involved the public, staff and external partners to sustain high quality and sustainable care.
  • The way the practice was led and managed promoted the delivery of high quality, person-centred care and an inclusive, supportive environment for staff. There was a focus on continuous learning and improvement at all levels of the practice. Where we identified any concerns during our inspection, the practice took immediate action to respond or plans of action were in place to ensure any issues were resolved.

We found breaches of regulations. The provider must:

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

The provider should:

  • Continue to audit staff personnel files and take action to address gaps in practice recruitment procedures.
  • Continue to manage and complete all appraisals in accordance with the practice policy.
  • Continue to take action to increase the uptake of cervical screening and childhood immunisations.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

27 January 2020

During an inspection looking at part of the service

We carried out an announced inspection at Westcroft Health Centre on 9 July 2019. The overall rating for the practice was good with the practice rated as requires improvement for being safe.

From the inspection on 9 July 2019, the practice was told they must:

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

In addition, the practice was told they should:

  • Routinely complete and review risk assessments, including those relating to health and safety, premises, security, water safety and fire. Ensuring all identified actions are completed in a timely manner.
  • Monitor performance of the cleaning contractors and ensure plans to implement regular deep cleaning of carpets are realised.
  • Improve maintenance of staff records ensuring consistencies in records kept, particularly for reference requests and completed inductions.
  • Maintain records of clinical supervision to support staff employed in advanced roles. Complete all outstanding appraisals for staff.
  • Continue to monitor the results of the national GP patient survey and patient satisfaction with access to appointments, particularly when trying to contact the practice by telephone.

The full comprehensive report on the inspection carried out in July 2019 can be found by selecting the ‘all reports’ link for Westcroft Health Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection undertaken on 27 January 2020 as part of our inspection programme to follow up on concerns identified at our previous 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 have rated this practice as good overall and good for all population groups.

We found that:

  • Systems and processes to reduce risks to patient and staff safety had been strengthened, in particular those relating to staff immunity status and the availability of appropriate emergency medicines.
  • There was a systematic approach to reviewing and maintaining risk assessments and practice policies. Required actions identified following risk assessments were recorded in action plans and resolved as needed.
  • Maintenance of staff records had been improved and records we reviewed demonstrated a uniform approach to both recruitment and record keeping.
  • Systems to support effective clinical supervision and appraisals had been developed. The practice was due to commence a 360 appraisal programme for all staff. Managers had been appropriately trained to support effective implementation of the new appraisal system.
  • The practice had reviewed appointment access and was working continuously to improve patient satisfaction. In particular, the practice had actively promoted online services, to encourage patients to book appointments online where possible. Telephone lines had been increased from eight to 12 and staffing had been restructured to ensure as many staff as possible were answering telephones during busy periods. On the day of our inspection, we saw there were multiple same day appointments available with the duty doctor and another GP.
  • The NHS 111 service were able to book appointments directly with the practice for patients contacting them whom required urgent appointments.

The areas where the provider should make improvements are:

  • Ensure planned works to replace all carpeted flooring with appropriate clinical flooring is completed in a timely manner.
  • Continue to monitor the results of the national GP patient survey and patient satisfaction with access to appointments, particularly when trying to contact the practice by telephone.

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

9 July 2019

During an inspection looking at part of the service

We carried out an announced inspection at Westcroft Health Centre on 9 July 2019 as part of our inspection programme. We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions:

  • Safe
  • Effective
  • Responsive
  • Well-led

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 good overall and good for all population groups. The practice was rated as requires improvement for providing safe services.

We found that:

  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

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

  • Systems and processes to reduce risks to patient and staff safety needed strengthening.
  • Risks to patients and staff had not adequately been assessed, in particular those relating to staff immunity status and the availability of appropriate emergency medicines.

The areas where the provider must make improvements are:

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

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

The areas where the provider should make improvements are:

  • Routinely complete and review risk assessments, including those relating to health and safety, premises, security, water safety and fire. Ensuring all identified actions are completed in a timely manner.
  • Monitor performance of the cleaning contractors and ensure plans to implement regular deep cleaning of carpets are realised.
  • Improve maintenance of staff records ensuring consistencies in records kept, particularly for reference requests and completed inductions.
  • Maintain records of clinical supervision to support staff employed in advanced roles. Complete all outstanding appraisals for staff.
  • Continue to monitor the results of the national GP patient survey and patient satisfaction with access to appointments, particularly when trying to contact the practice by telephone.

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

24 February 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Westcroft Health Centre on 24 February 2015.

The practice achieved an overall rating of Good. This was based on our rating of all of the five domains. Each of the six population groups we looked at achieved the same good rating.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Information about services and how to complain was available and easy to understand.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.

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

Importantly the provider should:

  • Ensure the role specific training update for the GP safeguarding lead has been completed as planned
  • Review the infection control policy, the associated training and audit so control measures and lead roles are made explicit to practice staff
  • Make all possible efforts to increase the membership of the Patient Participation Group (PPG)
  • Ensure the new appraisal system is implemented and embedded across all staff groups
  • Improve patient experience during GP consultation so they feel involved in their care and treatment
  • Explore ways to manage the growing practice list size and create improved access to appointments for patients
  • Ensure policies and procedures reflect and comply with the requirements of legislation and directives

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice