Westseven GP

We carried out an announced comprehensive at Westseven GP on 27 July 2022. Overall, the practice is rated as Good.

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Why we carried out this inspection

This was a comprehensive inspection. This was a new registration and we carried out this inspection as part of our regulatory functions.

At this inspection we covered all key questions:

• Are services safe?
• Are services effective?
• Are services caring?
• Are services responsive?
• Are services well-led?

How we carried out the inspection

Throughout the pandemic, CQC has continued to regulate and respond to risk. At this inspection, we visited the practice which included:

• Conducting staff interviews.
• 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.

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 rated the practice as requires improvement for providing safe services.

We found that:

• The practice did not have any formal monitoring system in place to assure themselves that blank prescription forms and handwritten pads were recorded, and their use was monitored in line with national guidance.
• Patients received effective care and treatment that met their needs, with the exception of those relating to the monitoring of some high risk medicines.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The Patient Participation Group (PPG) was active.
• The practice carried out repeated clinical audits.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. 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-centred care.

We found a breach of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

• Carry out appropriate health checks during the recruitment process.
• Arrange sepsis awareness training.
• Develop a system to monitor repeat prescription box to ensure requesting and collecting repeat prescriptions process works effectively.
• Continue to encourage and monitor cervical cancer screening and childhood immunisation uptake rates.
• Review the process of identifying carers to enable them to access the support available via the practice and external agencies.

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