The Care Quality Commission
  • Doctor
  • GP practice

West Meads Surgery

Overall: Good read more about inspection ratings

2-8 The Precinct, West Meads, Bognor Regis, West Sussex, PO21 5SB (01243) 837980

Provided and run by:
West Meads Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about West Meads Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about West Meads Surgery, you can give feedback on this service.

6 June 2022 and 9 June 2022

During a routine inspection

We carried out an announced inspection at West Meads Surgery on 6th and 9th June 2022 Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - not inspected (Good, carried over)

Responsive – inspected, access questions only (Good, carried over)

Well-led - Good

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

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated Good or Outstanding, to test the reliability of our new monitoring approach. This inspection was a comprehensive inspection that focused on the following key questions:

  • Safe
  • Effective
  • Responsive (access questions only)
  • Well-led

How we carried out the inspection.

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included: -

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.
  • A staff questionnaire.

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 have rated this practice as Good overall

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 had an active patient participation group and patient views were acted on to improve services and culture.
  • Patients could access care and treatment in a timely way.
  • Staff felt supported by their managers and that their well-being was prioritised.
  • Staff had the training and skills required for their role.
  • 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:

  • Ensure staff vaccination records of all staff are complete, and appropriate risk assessments are undertaken where necessary.
  • Continue to improve systems and structures for assuring the competence of staff in advanced clinical roles and ensure comprehensive records are kept.
  • Review all patients on dependency forming medicines and implement plans to reduce prescribing.
  • Ensure that historical safety alerts are included within current systems and processes.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

22 August 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

Our previous comprehensive inspection at West Meads Surgery in Bognor Regis, West Sussex on 5 October 2016 found breaches of regulations relating to the safe and well-led delivery of services. The overall rating for the practice was requires improvement. Specifically, we found the practice to require improvement for the provision of safe and well led services. The practice was rated good for providing effective, caring and responsive services. The concerns identified as requiring improvement affected all patients and all population groups were also rated as requires improvement. The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for West Meads Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 22 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the four breaches in regulations that we identified in our previous inspection in October 2016. This report covers our findings in relation to those requirements and improvements made since our last inspection.

We found the practice had made improvements since our last inspection. At our inspection on the 22 August 2017 we found the practice was meeting the regulations that had previously been breached. We have amended the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective, caring, responsive and well led services. Overall the practice is now rated as good. All six population groups have also been re-rated following these improvements and are also rated as good.

Our key findings were as follows:

  • There was an overarching governance framework which supported the delivery of safe and good quality care. Improvements had been made after the October 2016 inspection to deliver progress in improving services. These improvements included improvements in safeguarding arrangements, recruitment and health and safety.
  • The practice was effectively managing training arrangements, which were consistent and embedded across all staff groups. Training and professional development was managed and recorded on a system which identified when staff had training and when it would need to be refreshed.
  • The practice had revised recruitment processes and supporting documentation including Disclosure and Barring Service checks. Recruitment procedures were operated effectively to satisfy that staff employed were of good character, such as obtaining references, conducting disclosure and barring scheme checks for clinical staff, identification and employment history.
  • The practice had established and was operating safe and effective systems to assess, manage and mitigate the risks identified relating to electrical safety, legionella, gas safety and oxygen storage.
  • National guidance had been embedded into the practice regarding the provision of chaperones (a chaperone is a person who acts as a safeguard and witness for a patient and health care professional during a medical examination or procedure). This included appropriate training and completed background checks.
  • Individual comprehensive risk assessments had been completed for all practice staff who visit patients away from the practice. This was supported by a revised lone working policy.
  • To further support and sustain the level of improvements, we saw the practice formally documented and communicated to all staff the practice governance, strategy and supporting business plan. Furthermore, we saw this included information on the practice emergency procedures, including access to the business continuity plan.
  • The practice had taken steps to improve the suitability of the premises for patients who have mobility problems.
  • Suitable arrangements and supporting processes were in place for planning and monitoring the number of staff and mix of staff needed to meet patients’ needs.
  • An on-going schedule of audits had been formalised to continually assess, monitor and improve the quality of services. We saw this schedule ensured audit activity was monitored and confirmed recommendations and follow up audits were planned and completed.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

5 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at West Meads Surgery on 5 October 2016. Overall the practice is rated as requires improvement.

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

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. The 31 patient comment cards we received and three patients we spoke with on the day of the inspection all stated they were happy with the care and treatment they received.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Most staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Most risks to patients were assessed and well managed. However, some systems and processes to address risks were not implemented well enough to ensure patients and staff were kept safe. This included the completion of recruitment checks, staff training including for safeguarding and chaperoning, and lack of risk assessments and mitigation of risk for the premises including for disabled patients or those with mobility problems.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported.
  • The practice had a number of policies and procedures to govern activity, but some had not been dated, were overdue review or contained out of date information.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • The practice proactively sought feedback from staff and patients, which it acted on
  • The patient participation group was active and had made a number of improvements to the practice.

The areas where the provider must make improvement are:

  • Ensure that all documents and processes used to govern activity are practice specific and up to date. This includes adult and child safeguarding arrangements, significant events, chaperoning, recruitment, consent and lone working.
  • Ensure all staff are up to date with training appropriate to their job role; including adult and child safeguarding, infection control and information governance.
  • Ensure recruitment procedures are established and operated effectively to satisfy that staff employed are of good character, such as obtaining references, conducting disclosure and barring scheme checks for clinical staff, identification and employment history.
  • Ensure the risks to the health and safety of patients and staff has been assessed and mitigated where reasonably possible, including for electrical safety, legionella, gas safety and that areas where oxygen is stored are clearly signed.
  • Ensure that staff who are chaperones receive suitable training and a disclosure and barring scheme check.
  • Ensure that staff who conduct home visits receive a comprehensive risk assessment, as per the practice lone working policy.
  • Formally document and communicate to all staff the practice governance, strategy and supporting business plan, including information on the practice emergency procedures, including access to the business continuity plan.

In addition the provider should:

  • Ensure that the premises is suitable for disabled patients and those who have mobility problems.
  • Ensure there are processes in place to satisfy that there are sufficient numbers of suitably qualified, competent, skilled and experienced staff deployed in order to meet patients’ care and treatment needs, particularly during periods of absence.
  • Ensure there are systems and processes in place to assess, monitor and improve the quality and safety of the services being provided by ensuring an on-going audit programme is monitored and acted upon.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice