The Care Quality Commission
  • Doctor
  • GP practice

Westminster Surgery

Overall: Good read more about inspection ratings

12-18 Church Parade, Ellesmere Port, Merseyside, CH65 2ER (0151) 355 4864

Provided and run by:
Cheshire and Wirral Partnership NHS Foundation Trust

Important: This service was previously registered at a different address - see old profile

All Inspections

22 January 2020

During an annual regulatory review

We reviewed the information available to us about Westminster Surgery on 22 January 2020. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

20/05/2019

During an inspection looking at part of the service

We carried out an announced comprehensive inspection of Westminster Surgery on 29 August 2018 as part of our inspection programme. The overall rating for the practice was requires improvement as we found shortfalls for the responsive and well-led domains. The full comprehensive report on the August 2018 inspection can be found by selecting the ‘all reports’ link for Westminster Surgery on our website at www.cqc.org.uk.

This inspection was carried out on 20 May 2019 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 29 August 2018. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.


Overall the practice is now rated as Good. The population groups are also rated as good.

Our key findings were as follows:

  • The provider had reviewed the system for managing complaints to ensure there was an effective system for identifying, receiving, recording, handling and responding to complaints.

  • The provider had taken action to improve their governance systems.

  • The provider had taken action to ensure the service was now registered for the regulated activity of Surgical procedures.

  • The provider had taken action to address the areas where we advised them that improvements should be made. Improvements had been made to the procedures for the security of prescriptions. The procedure for the safe management of uncollected prescriptions had been revised, however the written procedure needed to be updated to demonstrate that a clinician was reviewing these prescriptions. A revised system to document the action taken in relation to safety alerts had been introduced. Action had been taken to encourage the reporting of incidents and near misses and the provider had revised their protocols for managing staff changes.
  • The provider had taken action to identify and if possible increase the number of carers and to address low patient satisfaction rates in respect of accessing the surgery by telephone and making appointments.

The areas where the provider should make improvements are:

  • Update the procedure for uncollected prescriptions to indicate that a clinician is reviewing these.
  • Record all measures used to investigate complaints so it is clear how the outcome was reached.

29/8/2018

During a routine inspection

This practice is rated as requires improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Westminster Surgery on 29th August 2018 as part of our inspection programme.

At this inspection we found:

  • Westminster Surgery is a GP practice and is part of Cheshire and Wirral Partnership NHS Foundation Trust. The Trust had clear governance systems to monitor staffing, recruitment, staff training and appraisals, incidents and complaints. However, on the day of our inspection we found that the practice had struggled because of staffing issues over the past 12 months, including not having a full-time practice manager; and consequently, governance arrangements were not cohesive at location level. Trust wide governance arrangements, were not always fully implemented at the practice location. Governance arrangements, responsibilities and managing risks required improvement at practice level.
  • The practice carried out the regulated activity of minor surgery but was not registered with the Care Quality Commission to do so.
  • The practice ensured that care and treatment was delivered according to evidence- based guidelines. However, there was a lack of a clinical audit programme and a regular monitoring system for high risk medications.
  • Staff involved and treated patients with compassion, kindness, dignity and respect. Clinicians we spoke with were passionate about providing person centred care.
  • The most recent results from the GP national patient survey (August 2018) showed lower than average patient satisfaction rates with being able to contact the surgery by telephone and general satisfaction with the service. The practice had recently changed its appointment systems.
  • There was no effective system for managing verbal complaints.
  • There was a strong focus on continuous learning and improvement. However, due to staffing issues the practice had struggled to implement their plans.
  • The practice engaged with local community organisations and charities to support patients. They had embraced new technology to improve communications and provide additional support for patients.

The provider must:

  • Not carry out the regulated activity of minor surgery at the practice until registered to do so.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care at the practice.
  • Ensure there is an effective system for identifying, receiving, recording, handling and responding to all complaints by patients and other persons in relation to the carrying on of the regulated activity at the practice.

The areas where the provider should make improvements are:

  • Review the system for safety alerts received by the practice to ensure action taken is documented.
  • Remove blank prescriptions from printers overnight and keep them in secure place (or have lockable printers).
  • Review the uncollected prescriptions policy for vulnerable patients to ensure clinicians view the reasons for uncollected prescriptions before destruction.
  • Review how contingency plans are managed for practice protocols when there are staff changes.
  • Reduce the threshold for reporting incidents and near misses and continue to support staff to report these.
  • Act to address the low patient satisfaction rates in respect of patients contacting the surgery by telephone and making an appointment.
  • Review methods to identify and increase their list of carers to enable the practice to provide support.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.