We previously carried out an announced comprehensive inspection at Westwood Medical Health Centre on 15 November 2016. The overall rating for the practice was good, with a requires improvement rating for providing well-led services.

We subsequently carried out an announced focused inspection on 25 October 2017 where we found evidence of some improvements. However, we found the provider had still not ensured that there were effective governance and assurance processes to monitor the service in all areas of the practice. Consequently, the practice remained rated as requires improvement for providing well-led services, and was rated good overall.

The full comprehensive report for the November 2016 inspection and the focused report for the October 2017 inspection can be found by selecting the ‘all reports’ link for Westwood Medical Health Centre on our website at

www.cqc.org.uk.

This inspection was a desk-based review carried out on 20 November 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspections during November 2016 and October 2017. 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.

Our key findings were as follows:

• The practice had established effective systems and processes to ensure good governance in accordance with the fundamental standards of care. Specifically, the practice had implemented an effective process to monitor and respond to Medicines and Healthcare products Regulatory Agency (MHRA) alerts consistently. This included carrying out the appropriate actions to ensure patients were not affected by the alerts.
• The practice had reviewed and implemented a revised procedure for transporting oxygen safely in an emergency.
• The practice had implemented a process to consistently record the content of discussions, decisions and proposed actions at all meetings.

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 Westwood Medical Health Centre on 15 November 2016. The overall rating for the practice was good. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Westwood Medical Health Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection which was carried out on 25 October 2017 to confirm that the practice had completed their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 15 November 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 collection of urine samples was carried out in an appropriate manner at both the main and branch practices. Disposable gloves were available if needed. A plastic jug was no longer used at the branch practice.
• Staff had received updated training in infection prevention and control.
• We saw evidence that the fridge temperature of the vaccine fridge at the branch surgery was tested every day and documented. Plugs at the main and branch practices had labels advising that they should not be switched off.
• There was a system for documenting the transportation of vaccines between the main and branch practices.
• We saw that locum recruitment checks were carried out before employment.
• Best practice guidance from the National Institute for Health and Care Excellence (NICE) was implemented and shared.
• The system for receiving, circulating, actioning and tracking alerts from the Medicines and Healthcare products Regulatory Agency (MHRA) was not effective.
• The system for tracking prescription stationery in the practice was well-embedded.
• Oxygen was not stored in an easy to carry/protective case.
• All staff were encouraged to report incidents and events within the practice.
• Although incidents and events and complaints were discussed and analysed at a meeting with senior staff, no formal records were kept. There was no audit trail of the discussion and learning points that took place.
• Verbal complaints were recorded as well as written complaints.
• Full practice meetings had not yet taken place, although one was scheduled for January 2018.
• There was a business continuity plan and staff knew how to access it.

However, there were areas of practice where the provider needs to make improvements.  

Importantly, the provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition the provider should:

• Review the procedure for transporting oxygen safely in the event of an emergency.
• Review the procedure for recording discussions at meetings to provide a full account of the decisions and learning outcomes so that there is an audit trail.

At our previous inspection on 15 November 2016, we rated the practice as requires improvement for providing well-led services as the practice had not ensured effective governance and assurance processes to monitor the service in all areas of the practice. At this inspection we found that the provider had still not ensured that there were effective governance and assurance processes to monitor the service in all areas of the practice. Consequently, the practice is still rated as requires improvement for providing well-led 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 Westwood Medical Health Centre on 15 November 2016. Overall, the practice is rated as good overall and requires improvement for providing a Well Led service.

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

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
• 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.
• Information about services and how to complain was available and easy to understand and improvements were made to the quality of care as a result of complaints and concerns.
• The practice had no system in place to ensure they followed NHS Protect security of prescription forms guidance, but during the inspection commenced this process.
• The practice lacked a documented process on how they shared and acted upon National Institute for Health and Care Excellence (NICE) best practice guidance and the Medicines and Healthcare products Regulatory Agency (MHRA) alerts.
• Risks to patients were assessed and well managed with some exceptions. These included; an infection prevention and control process, fridge temperature monitoring, cold chain documentation when transporting vaccines between the main and branch practices, and the completion of locum recruitment checks.
• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group.
• The practice paid for car parking facilities for its patients based at the rear of the practice.
• The practice had visible clinical and managerial leadership and governance arrangements.

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

• Ensure measures are in place to assess the risk of, and prevent, detect and control the spread of infections, particularly in relation to the collection of urine samples, and take measures to ensure staff complete update training in Infection Prevention and Control.

• Ensure the proper and safe management of medicines, particularly in relation to the cold chain arrangements, the vaccine fridge temperatures at the branch practice, the transportation of vaccines between sites and the security of fridge plugs.

• Ensure all recruitment checks including those of locum staff, are appropriately received and are complete prior to employment.

• Put systems in place to demonstrate how the practice implements and shares National Institute for Health and Care Excellence (NICE) best practice guidance and the Medicines and Healthcare products Regulatory Agency (MHRA) alerts including searches and any action taken.

There were areas of practice where the provider should make improvements:

• Monitor the implementation system started during the inspection that follows NHS Protect Security of prescription forms guidance.

• Consider how staff would safely transport any medicines including oxygen required in the event of an emergency.

• Encourage all staff to report incidents and events within the practice.

• Document the comments received and actioned from those made by patients verbally as well as formal complaints to inform any trend analysis.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice