Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Western Ave Medical Centre on 26 July 2016. The overall rating for the practice was good, however the practice was rated as requires improvement for providing safe services. We carried out a desk-based review on 20 January 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 26 July 2016. The practice had met the legal requirements and continued to be rated as good, however we rated the practice as requires improvement for providing effective services as staff had not received the training needed for their roles. The full comprehensive report on the July 2016 inspection and the desk based review in January 2017 can be found by selecting the ‘all reports’ link for Western Ave Medical Centre on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 18 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection on 20 January 2017. This report covers our findings in relation to those requirements.

Overall the practice is rated as good.

Our key findings were as follows:

• Staff were receiving the training needed for their roles.

We found that the provider should make the following improvements:

•  The practice should develop a system to support annual updates of training in safe working practices.

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 of Western Ave Medical Centre on 26 July 2016. The overall rating for the practice was Good. The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for Western Ave Medical Centre on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 20 January 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 26 July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated as Good.

Our key findings were as follows:

• The provider had ensured the premises were safely maintained. Evidence of a satisfactory electrical wiring inspection had been made available.

• Action had been taken to ensure that a record of the required staff recruitment information was maintained.

The following improvements to the service had also been made:

• A system for documenting reviews of significant events had been introduced.

• A system for demonstrating that patient safety alerts were being received and the action taken was in place.

• Action had been taken to ensure the safety of the premises. Regular checks of the emergency lighting were taking place and action had been taken to address the security risk presented by the windows.

• Further information about the role and remit of the medical scribe (staff member who records patient consultations) had been made available for patients.

• The procedure clinical staff follow to ensure their equipment and instruments are suitably cleaned was being recorded.

There were areas of practice where the provider must make improvements are:

• Staff must receive the training necessary for their roles.

At our previous inspection we identified that the service should improve their training records to assist with the monitoring and planning for staff training needs. At this visit this had been completed. However this identified a number of training shortfalls. A training plan was provided showing how these shortfalls were to be addressed over the next six months. As a consequence of the outstanding training the practice is rated as requires improvement for providing effective services.

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 Western Ave Medical Centre on 26th July 2016.

Overall the practice is rated as good.

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

• There were systems in place to reduce risks to patient safety, for example, infection control procedures, medication management and the management of staffing levels. Improvements were needed to the records of recruitment to demonstrate the suitability of staff employed.

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Staff were aware of procedures for safeguarding patients from the risk of abuse.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance.

• Staff felt well supported. They had an annual appraisal and told us they had received training appropriate to their roles.

• Patients were positive about the care and treatment they received from the practice. The National GP Patient Survey January 2016 showed that patients’ responses about whether they were treated with respect, compassion and involved in decisions about their care and treatment were overall comparable to local and national averages.

• Services were planned and delivered to take into account the needs of different patient groups.

• The National GP Patient Survey results showed that patient’s satisfaction with access to care and treatment was generally in line with local and national averages.

• Information about how to complain was available. There was a system in place to manage complaints.

• There were systems in place to monitor and improve quality and identify risk.

However there were areas of practice where the provider must make improvements:

• The provider must ensure that there is a record of the required recruitment information to confirm the suitability of staff employed.

• Ensure that the electrical wiring at the premises is safe.

The areas where the provider should make improvements are:

• Document reviews of significant events to demonstrate that actions identified have been implemented.

• Clearly demonstrate that patient safety alerts are being received and the action taken.

• Ensure the safety of the premises by carrying out regular checks of the emergency lighting and by taking appropriate action to address the security risk presented by the windows.

• The records of all staff training should be improved to assist in monitoring and planning for the training needs of staff.

• A procedure around the use of a medical scribe (staff member who records patient consultations) which detailed their role and remit should be developed.

• The procedure clinical staff follow to ensure their equipment and instruments are suitably cleaned should be recorded.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice