We carried out an announced comprehensive inspection at Westcotes Health Centre on 17 January 2019 as part of our inspection programme to see whether the breaches we identified at our previous inspection on 15 November 2016 had been addressed.

At the last inspection in November 2016 we rated the practice as requires improvement for providing safe services because:

• The practice did not have systems in place to properly assess and mitigate against risks associated with infection prevention and control.
• The practice did not have an effective process in place for reporting recording, acting on and monitoring significant events, incidents and near misses.

At this inspection, we found that the provider had addressed these breaches of regulations.

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 and
• 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 found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• 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.

Whilst we found no breaches of regulations, the provider should:

• Review the protocol for staff removing items of post without sight of a GP.
• Improve the monitoring of loose prescriptions allocated to specific printers.
• Introduce an ongoing summary of significant events to better identify trends and review actions taken as a result of incidents.
• Continue to improve the identification of carers to enable this group of patients to access the care and support they need.

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

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 Westcotes Health Centre on 15 November 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events however, there were some inconsistencies in the system and it required review.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available for patients.
• Risks to patients were assessed and well managed. With the exception of environmental audits in relation to infection control which had not been carried out.
• The practice had made significant improvement to Qof performance however, patient outcomes were hard to identify as little or no reference was made to audits or quality improvement with the exception of medicines management audits that had been carried out.
• Childhood immunisations were carried out in line with the national childhood vaccination programme. Uptake rates for the vaccines given were higher than CCG/national averages.
• The practice had a proactive patient participation group and had sought feedback from patients.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Patients we spoke with 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.
• 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 the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Review processes for reporting, recording, acting on and monitoring significant events, incidents and near misses. Ensure actions agreed to ensure lessons learned following discussion of a significant event are documented with timely review dates.

• Review process for carrying out regular infection prevention and control audits in the practice and implementing action plans. Ensuring infection control lead receives an appropriate level of infection control training.

The areas where the provider should make improvement are:

• Review process and methods for identification of carers and the system for recording this. To enable support and advice to be offered to those that require it.

• Review processes in place in relation to clinical audits to ensure full cycle audits are carried out to improve patient outcomes.

• Review system of appraisals to ensure all members of staff receive an appraisal at least annually.

• Review complaints processes to keep a record of informal complaints received.

• Ensure a copy of the business continuity plan is accessible by key persons out of hours in the event of an emergency.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice