Background to this inspection
Updated
17 March 2021
Westcotes GP Surgery is located at 2 Westcotes Drive, Leicester, Leicestershire, LE3 0QR. The practice is situated in a converted house; providing NHS services to the local community. Dr Shafiq Shafi and Partners are the providers of Westcotes GP Surgery and another neighbouring practice both of which are separate locations for the purpose of registration with the Care Quality Commission (CQC).
As part of this inspection, we visited Westcotes GP Surgery. Westcotes GP Surgery registered with CQC since July 2017 to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning, surgical procedures and treatment of disease, disorder or injury. Westcotes GP Surgery is situated within Leicester City Clinical Commissioning Group (CCG). Westcotes GP Surgery patient list totals 3,500 patients under the terms of a GMS contract.
Practice staffing comprises a principle GP partner (male), two GP associates (both male) and a silent GP partner who was not directly involved in the day to day running of the service. In the event of the principle GP being unable to work then the silent partner would be appointed as clinical lead. The clinical team also includes a practice nurse and a health care assistant. The non-clinical team consists of a seconded practice manager from the Primary Care Network (PCN), and a team of receptionists.
Westcotes GP Surgery is a teaching practice providing placements for second foundation year (FY2) doctors (a grade of medical practitioners undertaking a foundation programme which forms the bridge between medical school and general practice training). At the time of our inspection, there were two FY2 doctors at the practice.
Westcotes GP Surgery is in one of the more deprived area of Leicester. The practice scored two on the deprivation measurement scale; the deprivation scale goes from one to 10, with one being the most deprived. People living in more deprived areas tend to have greater need for health services. National General Practice Profile describes the practice ethnicity as being 72% white British, 14% Asian, 7% black, 4% mixed and 2% other non-white ethnicities. The practice demographics show the average percentage of people in the 65+ to 75+ year age group were
Updated
17 March 2021
We carried out a comprehensive inspection at Westcotes GP Surgery on 9 December 2020. Due to the impact of the COVID-19 pandemic, the majority of evidence reviewed, and staff interviews were undertaken remotely in advance of the site visit on 9 December.
The practice had previously received a comprehensive inspection in October 2019 when it received an overall rating of inadequate. The safe, effective and well-led domains were rated as inadequate, and the caring and responsive domains were rated good. All population groups were rated as inadequate. The practice was placed in special measures and two warning notices were issued, relating to safe care and treatment, against the provider.
We carried out a follow up inspection in February 2020 to check that the provider had addressed the concerns highlighted within the two warning notices. We found that the provider had taken action and the warning notices had been complied with.
You can read the comprehensive inspection reports by selecting the 'all reports' link for Westcotes GP Surgery on our website at www.cqc.org.uk
Following our inspection in December 2020, the practice is now rated as good overall. The practice is also rated as good for providing safe, caring, responsive and well-led services and requires improvement for effective services.
Population groups were rated as requires improvement for people with long-term conditions, families children, young people, and working age people, and good for older people, people whose circumstances make them vulnerable, and people experiencing poor mental health (including people with dementia) in the effective domain. All population groups are rated as good in the responsive domain.
The service is now rated as good for providing safe services because:
- The practice had developed systems and processes which ensured care was delivered in a safe way. The lead GP had taken overall charge of the practice and we saw that this oversight had meant the way risk was monitored and managed had become routine and all staff had contributed to the changes and it was embedded in day to day patient care.
The service is now rated as requires improvement for providing effective services because:
- Although systems and processes were now in place and the practice staff were allocated areas of specialty to ensure patients are appropriately managed, the data showed the practice remained below national averages across a range of indicators. We were mindful that changes take time to show improvements in areas such as long-term conditions management.
The service is now rated as good for providing caring services because:
- Staff treated patients with kindness and respect and involved them in decisions about their care. Patients were positive regarding the quality of care they received from practice staff which was shown in the latest survey results.
The service is now rated as good for providing responsive services because:
- The practice organised services to meet patients’ needs. Patients could access care and treatment in a timely way.
- Care had continued to be delivered in a responsive way during the pandemic. Additional audits were carried out to ensure shielded patients were aware of the additional support available and options should they require an appointment.
The service is now rated as good for providing well-led services because:
- The practice had undergone significant change of leadership in the midst of a pandemic and had utilised this to ensure positive change. Staff we spoke to told us the changes had been very positive and the management team were now approachable and instigated change with the involvement of staff. Staff told us this had a direct benefit on the moral and staff were more engaged and able to deliver better patient care.
While there has been significant improvement the provider should:
- Review the systems put in place to monitor the changes which have led to improvements in performance to ensure it continues.
I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.
Details of our findings and the evidence supporting our ratings are set out in the evidence table.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care