Letter from the Chief Inspector of General Practice

In April 2016 a comprehensive inspection of Westfield Surgery was conducted. The practice was rated as requires improvement overall, specifically we found the practice required improvement for safe and well led services and was good for providing effective, caring and responsive care.

We found that the practice required improvement for the provision of safe services because improvements were needed in the way the practice assessed the risks to the health and safety of service users who were receiving care and treatment, specifically in relation to the control and monitoring of legionella and hazardous substances (legionella is a term for a particular bacterium which can contaminate water systems in buildings).

We also found that the practice required improvement for well led because improvements were needed to ensure staff had received essential training and appraisals, risk assessments needed to be completed and reviewed regularly and a system needed to be in place to monitor the security of blank prescriptions.

Westfield Surgery sent us an action plan that set out the changes they would make to improve these areas.

We carried out an announced focussed inspection of Westfield Surgery on 8 December 2016 to ensure the practice had made these changes and that the service was meeting regulations. At this inspection we rated the practice as good for providing safe and well led services. The overall rating for the practice is now good. For this reason we have only rated the location for the key questions to which this related. This report should be read in conjunction with the full inspection report of 7 April 2016. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Westfield Surgery on our website at www.cqc.org.uk.

Our key findings were:

• The practice had processes in place to maintain and monitor the security of blank prescriptions.
• Risk assessments had been completed and policies implemented for legionella and hazardous substances.
• A business continuity plan was in place and other policies and risk assessments had been recently reviewed and updated.
• Recommended training had been undertaken by practice staff and staff appraisals had been undertaken.
• Lessons learnt from significant events and complaints were shared to drive improvement.
• Action had been taken to actively seek the views of service users.

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 Westfield Surgery on 7 April 2016. Overall the practice is rated as requires improvement.

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

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients said they found it easy to make an appointment with a named GP and 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.
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were discussed but lessons learnt were not shared to support improvement.
• The practice had a number of policies and procedures to govern activity, but some were overdue a review.
• The arrangements for identifying, recording and managing risks, issues and implementing mitigating actions were not robust, for example a legionella assessment had not been completed.
• Not all staff had received mandatory training, for example, fire safety training and information governance.
• There was a limited approach to obtaining the views of people who use the services and other stakeholders.
• To promote ream working and an appeciation of total practice working the GPs had initiated a day where the administrative staff attended an away day and the GPs ran the practice for the day. This had led to the GPs appreciating the challenges that reception staff faced and changing practice systems around appointments.

The areas where the provider must make improvements are:

• Ensure risk assessments across a number of areas are completed and reviewed to ensure the identification, recording and management of risks.
• Ensure all staff receive mandatory training and that all staff have had an appraisal.
• Review governance arrangements for policies and procedures, to include storage of blank prescriptions, the sharing of learns following significant events to support, the management of risks, improvement, seeking and acting on the views of service users and a business continuity plan for major incidents.

In addition the provider should:

• Review and update procedures and guidance with regard to training and policies of chaperone duties.
• The practice should ensure more effective identification of patients who are also carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice