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.