Background to this inspection
Updated
26 September 2018
Willaston Surgery is registered with the Care Quality Commission to provide primary medical services. The practice is registered as a location under the provider Cheshire and Wirral Partnership NHS Foundation Trust. The trust provides a range of health services, including mental health services, across Wirral, Cheshire, Southport and Sefton areas. They operate two GP practices and the GP out of hours service for West Cheshire.
Willaston Surgery holds an Alternative Provider Medical Services (APMS) contract with NHS England.
The practice team consists of four GPs, one practice nurse, a practice manager and office manager, reception and administration staff.
The total practice list size is 4300. The practice is part of West Cheshire Clinical Commissioning Group (CCG). The practice is situated in a more affluent area that has lower than average areas of deprivation. The practice population is made up of a higher than national average population aged over 65 years and a lower than national average of younger aged patients.
It is registered to provide the following regulated activities:
Diagnostic and screening procedures
Family Planning
Maternity and midwifery services
Treatment of disease, disorder or injury
Out of hours primary medical services are accessed by calling NHS 111.
Updated
26 September 2018
This practice is rated as Good overall.
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
We carried out an announced comprehensive inspection at Willaston Surgery on 21 August 2018 as part of our inspection programme.
At this inspection we found:
- The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. However, improvements should be made so that all staff are familiar with and fully involved with the significant event learning and improvement process.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. Care and treatment was delivered according to evidence based guidelines.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
- There were systems in place to mitigate safety risks including health and safety, infection control and dealing with safeguarding.
- The practice had good facilities and was well equipped to treat patients and meet their needs. However, the premises had some constraints for access to patients with limited mobility. The practice made reasonable adjustments to accommodate these patients.
- There was a clear leadership structure and staff felt supported by management.
- The practice reviewed and considered patient views through surveys and feedback.
- Staff worked well together as a team, knew their patients well and all felt supported to carry out their roles.
- There was a focus on learning and improvement at all levels of the organisation.
- The provider was aware of the requirements of the duty of candour.
The areas where the provider should make improvements are:
- Review the implementation of policies that are specific to the practice, easily accessible and understandable and enable staff to effectively carry out their role
- Review training in the significant events and incident reporting policy and procedures to ensure staff are familiarised with the local policies and fully involved in the learning process.
- Review the security of the clinical waste bins stored outside the building.
- Review the system for safety alerts received by the practice to ensure action taken is documented.
- Review the inventory for medical equipment calibration to ensure all items are serviced and calibrated accordingly and no items are missed during the annual checks.
- Review the implementation of an audit plan or programme to include audits based on local, national and service priorities.
- Review methods to identify and increase the list of carers to enable the practice to provide appropriate support.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
Families, children and young people
Updated
26 September 2018
Working age people (including those recently retired and students)
Updated
26 September 2018
People experiencing poor mental health (including people with dementia)
Updated
26 September 2018
People whose circumstances may make them vulnerable
Updated
26 September 2018