Forty Willows Surgery in Wembley is a Doctors/GP specialising in the provision of services relating to diagnostic and screening procedures, family planning services, maternity and midwifery services, services for everyone, surgical procedures and treatment of disease, disorder or injury. The last inspection date here was 2nd July 2018
Forty Willows Surgery is managed by Forty Willows Surgery.
Contact Details:
Address:
Forty Willows Surgery 46 Forty Lane Wembley HA9 9HA United Kingdom
We carried out a previous focused inspection on 14 February 2018 to follow-up on a warning notice the Care Quality Commission served following an announced comprehensive inspection on 28 September 2017, when the provider was rated as inadequate for providing safe services.
The previous reports from the September 2017 and February 2018 inspections can be found by selecting the ‘all reports’ link for Forty Willows Surgery on our website at .
We carried out an announced comprehensive inspection at Forty Willows Surgery on 24 May 2018, to follow up on breaches of regulations. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions.
At this inspection we found:
The practice had made significant improvements since our previous inspection in September 2017.
The practice had clear 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.
The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that 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.
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 strong focus on continuous learning and improvement at all levels of the organisation.
The practice was aware of and complied with the requirements of the Duty of Candour.
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.
The practice demonstrated improvement in governance arrangements.
The areas where the provider should make improvements are:
Ensure all staff have received formal sepsis awareness training.
Review the system in place to promote the benefits of breast cancer national screening in order to increase patient uptake.
We carried out an announced focused inspection of Forty Willows Surgery on 14 February 2018. This was to follow-up on a warning notice the Care Quality Commission served following an announced comprehensive inspection on 28 September 2017 when the provider was rated as inadequate for providing safe services.
The warning notice, issued on 3 November 2017, was served in relation to regulation 12: Safe care and treatment, of the Health and Social Care Act 2008. The timescale given to meet the requirements of the warning notice was 5 February 2018.
The inspection on 28 September 2017 highlighted several areas where the provider had not met the standards of regulation 12: Safe care and treatment. We found:
The practice was unable to demonstrate their monitoring of medicines reviews for patients with long term conditions was always effective.
The practice was unable to demonstrate that they always followed national guidance on management and security of blank prescription forms.
The practice was unable to demonstrate that they had adequate health and safety related risk assessments and processes were in place to ensure safety of the premises and patients.
The comprehensive report from the September 2017 inspection can be found by selecting the ‘all reports’ link for Forty Willows Surgery on our website at www.cqc.org.uk and should be read in conjunction with this report.
At the inspection on 14 February 2018, we found that actions had been taken to improve the provision of safe services in relation to the warning notice. Due to the focussed nature of this inspection the ratings have not been reviewed. We will conduct a further comprehensive inspection within six months of publication of the report of the inspection undertaken in September 2017.
Our key findings were as follows:
The provider had demonstrated significant improvements in all areas highlighted in the warning notice.
The practice had reviewed and improved the systems in place to effectively monitor medicine reviews for patients with long term conditions.
The practice had carried out health and safety related risk assessments and checks, and remedial actions had been undertaken to ensure safety of the premises and patients.
Staff had undertaken fire safety and health and safety training.
Blank prescription forms were securely stored and there were systems in place to monitor their use. However, we noted that the serial numbers of blank prescription forms were not correctly recorded.
We noted that the ratings poster of previous Care Quality Commission inspection was not displayed in the premises. However, the practice had displayed the ratings poster on the day of inspection.
We noted that the previous Care Quality Commission inspection report had not been shared on the practice’s website. However, the practice had provided the evidence that the inspection report had been discussed with the patient participation group (PPG) and it was shared on the practice’s website on the day of inspection.
The areas where the provider should make improvements are:
Review the system in place for the recording of blank prescription forms.
Carry out control of substances hazardous to health (COSHH) risk assessments for the cleaning products stock in the premises.
Ensure the most recent CQC rating is clearly displayed.
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Forty Willows Surgery on 28 September 2017. Overall the practice is rated as requires improvement.
Forty Willows Surgery was previously inspected in October 2014 and was rated as good. The full comprehensive report on the October 2014 inspection can be found by selecting the ‘all reports’ link for Forty Willows Surgery on our website at www.cqc.org.uk.
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.
There were inconsistent arrangements in how risks were assessed and managed. For example we found risks relating to management of legionella, health and safety related risk assessments, safeguarding vulnerable adults and children training, basic life support training and management of blank prescription forms for use in printers which had not been monitored appropriately.
The practice was unable to demonstrate that all appropriate recruitment checks had been undertaken prior to employment.
The practice had a number of policies and procedures to govern activity, but most were not updated and reviewed regularly. Safeguarding policies did not include the correct name for lead staff.
Data showed patient outcomes were low for cervical, breast and bowel cancer national screening programme uptake and medicines reviews for patients with long term conditions.
The practice was unable to demonstrate that all staff had received up to date training relevant to their role. Staff appraisals had not always been completed in a timely manner.
We found that completed clinical audits cycles were driving positive outcomes for patients in some cases.
Patients we spoke with on the day informed us they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
Most of the patient’s feedback we received on the day informed us they were able to get appointments when they needed them.
There was a clear leadership structure and staff felt supported by management. However, there was limited evidence that the practice had proactively sought feedback from staff and patients.
The practice had good facilities and was well equipped to treat patients and meet their needs.
The provider was aware of the requirements of the duty of candour.
The areas where the provider must make improvements are:
Ensure care and treatment is provided in a safe way to patients.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
In addition the provider should:
Review and improve the systems in place to effectively monitor face to face reviews of patients with dementia.
Continue to monitor practice performance relating to exception reporting under the Quality Outcomes Framework.
Provide patient information in languages and formats suitable to the patient population.
Review the system in place to promote the benefits of cervical, breast and bowel cancer national screening in order to increase patient uptake.
Review and monitor the system in place to assure that all confidential documents are disposed of in a safe manner.
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Forty Willows Surgery on 21 October 2014. Overall the practice is rated as good.
Specifically, we found the practice to be good for providing safe, well-led, effective, caring and responsive services. It was also good for providing services for older people; people with long-term conditions; families, children and young people; people of working age; people whose circumstances may make them vulnerable and people experiencing poor mental health.
Our key findings were as follows:
The practice had effective systems in place to manage risks associated with medicines management, staff recruitment, infection control, child protection and medical emergencies.
The practice understood the needs of the population and had developed the service and skills of the staff team to meet patients’ needs. We found that care for long-term conditions such as mental health and diabetes was being managed effectively in the community and was provided in partnership with other specialist services.
Patient satisfaction scores were better than local averages for quality of care and in line with local averages for access to appointments. Twenty-five patients completed Care Quality Commission (CQC) comment cards about the service before our inspection. All of these were positive about the service and staff.
The practice was a training practice, providing placements for trainee GPs. We found that both the trainees and staff were well supported. Staff told us the practice was clinically and managerially well-led with opportunities to reflect on practice and improve.
However there were areas of practice where the provider needs to make improvements.
Importantly the provider must
Ensure that its website provides patients with accurate information about how to access primary care services when the practice is closed.
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