Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Western Road Medical Centre on 9 December 2015. Overall the practice is rated as good.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

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.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• There was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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 provider was aware of and complied with the requirements of the Duty of Candour.

The area where the provider should make improvement is:

• Ensure patient records are accurately coded, and introduce a system to avoid coding errors on patient records.

Professor Steve Field

CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We carried out an announced comprehensive inspection a Western Road Medical Centre on 12 February 2019 as part of our inspection programme.

We based our judgement of the quality of care at this service on a combination of: -

• what we found when we inspected,
• information from our ongoing monitoring of data about services,
• information from the provider, patients, the public and other organisations.

We have rated this practice as good overall and good for all population groups.

We have rated the provider good in effective, caring, responsive and well led because: -

• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• The practice had a culture which drove high quality sustainable care.
• The GP survey result scored 96% for patient overall experience.

We have rated safe as requires improvement this is because:

• At the time of the inspection the practice did not have an overall view to enable the monitoring of staff training. This had resulted in some staff not completing their mandatory safety training in child safeguarding awareness, infection control, fire and basic life support.

The areas where the provider must make improvements are:

• 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.
• (Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Review the governance systems to ensure that the provider can evidence that staff have completed the necessary training, and have had the appropriate immunisations.
• Review the prevention and management infections action plan to ensure progress is monitored and actions completed,
• Review the recruitment procedure all the correct documentation is obtained prior to a member of staff commencing work.
• Review the policies and procedures to ensure that they reflect the staff practices.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice