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