West Derby Medical Centre

Updated 23 November 2022

West Derby Medical Centre is located in the West Derby area of Liverpool, Merseyside. The address of the practice is: 3 Winterburn Crescent, Liverpool, Merseyside, L12 8TQ.

There were approximately 13,000 patients on the practice register at the time of our inspection. The practice population is mainly white British. Information published by Public Health England shows that deprivation within the practice population group is in the third lowest decile (3 of 10). The lower the decile, the more deprived the practice population is relative to others.

The provider is registered with CQC to deliver the Regulated Activities; Diagnostic and screening procedures, Maternity and midwifery services, Treatment of disease, disorder or injury, Surgical procedures and Family planning.

The practice is a teaching and training practice managed by 4 GP partners and there are 8 salaried GPs. There are 5 practice nurses and one advanced nurse practitioner (ANP). Members of clinical team are supported by a business and operations manager and a team of management, reception and administration staff.

The practice is open 8am to 6.30pm every weekday. Extended hours appointments are offered

Patients requiring a GP outside of normal working hours are advised to contact the GP out of hours service, by calling 111.

The practice has a General Medical Services (GMS) contract and has enhanced services contracts which include childhood vaccinations. The practice is part of the Cheshire and Merseyside Integrated Care Board.

The practice is part of a primary care network (PCN) which is a wider network of GP practices working in collaboration to provide and improve services across their locality

Updated 23 November 2022

We carried out an announced comprehensive inspection at West Derby Medical Centre on 4 October 2022. Overall, the practice is rated as Requires improvement.

Safe - Good

Effective – Requires improvement

Caring - Good

Responsive - Requires improvement

Well-led – Requires improvement

The full reports for previous inspections can be found by selecting the ‘all reports’ link for West Derby Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up concerns reported to us. The concerns related to patients reporting difficulties in accessing the practice by telephone and difficulties in obtaining an appointment. This was a comprehensive inspection where we looked at all key questions.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A short site visit.

Our findings

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 found that:

• Overall, the practice provided care in a way that kept patients safe and protected them from avoidable harm. However, some of the systems for monitoring medicines were not being used as effectively as they could.
• Review of patient records identified shortfalls in the monitoring of some care and treatment. There was no programme of effective clinical audit. Staff training and appraisals were not always up to date.
• The provider had taken action to improve patients experience and ensure all staff dealt with patients with kindness and respect. Patients were involved them in decisions about their care.
• Patients reported they could not always access care and treatment in a timely way as a result of difficulties in getting through to the practice by phone and associated delays in obtaining an appointment.
• Recent changes to the governance and performance management of the practice had been made, however the impact and sustainability of these changes was yet to be demonstrated.

We found a breach of regulation. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

• Continue to improve the uptake of childhood immunisations and cervical cancer screening.
• Review the effectiveness of work that has been outsourced and the impact of this on patient care and treatment.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services