Archived: Westwood Road Health Centre Also known as Westwood Road Surgery

Letter from the Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

At our previous comprehensive inspection at Westwood Road Health Centre on 16 December 2016 we found breaches of regulation relating to the safe care and treatment and good governance. The overall rating for the practice was requires improvement, specifically we found the practice to require improvement for the provision of safe, caring and well-led services. It was good for providing, effective, and responsive services. Consequently we rated all population groups as requires improvement. The previous inspection reports can be found by selecting the ‘all reports’ link for Westwood Road Health Centre on our website at www.cqc.org.uk.

This inspection was an announced inspection carried out on 1 August 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 16 December 2016. This report covers our findings in relation to those requirements and improvements made since our last inspection.

We found the practice had made the required improvements since our last inspection and was meeting the regulations that had previously been breached. We have amended the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective, caring, responsive and well led services. All six population groups have also been re-rated following these improvements and are also rated as good. Overall the practice is rated as good.

Our key findings were as follows:

• Infection control processes had been reviewed and improved since the last inspection.
• Prescription form security had been improved to ensure prescriptions could be tracked and monitored if they were lost or misused.
• Patient safety alerts were received, recorded and any action required was taken where necessary.
• A review of risk assessments had taken place including risks related to legionella, fire and patient transportation.
• Confidentiality at reception had been reviewed and improvements made to ensure sensitive information was not compromised.
• Patient feedback on the national GP survey had improved significantly since the last inspection.
• The practice had undertaken system reviews in areas where Care Quality Commission (CQC) identified problems in the last inspection and where staff and leaders had identified potential improvements to services themselves.
• Record keeping had been reviewed and improved to assist in the day to day management of the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Westwood Road Health Centre on 16 December 2016. Overall the practice is rated as requires improvement.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Although most risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe. For example, in relation to patient safety alerts, tracking of blank prescriptions, infection control, equipment servicing, and provision of patient transport.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• Staff had been trained to deliver care and treatment. However, there were not records of all staff having undertaken training in line with practice guidance.
• Most patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Reasonable measures to ensure patient confidentiality had not always been undertaken.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Most patients said that appointments were available when needed, with urgent appointments available the same day.
• There was a clear leadership structure and staff felt well supported by management. The practice sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Take all appropriate actions to respond to patient safety alerts.
• Track blank prescriptions through the practice in line with national guidance and maintain appropriate records.
• Ensure that all staff are aware of appropriate procedures relating to infection control.
• Implement further measures to protect patient confidentiality.
• Introduce systems to monitor that appropriate building risk assessments and checks have been undertaken at all premises.
• Ensure actions from audits are undertaken promptly and that equipment is appropriately serviced.
• Implement a risk assessment and plan for staff providing transport and delivering medicine to patients.

The areas where the provider should make improvement are:

• Introduce further systems to identify and support all carers registered at the practice.
• Implement further systems to ensure that all staff, including locum GPs have undertaken appropriate training and that this is documented.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice