Westwood Clinic

Updated 10 November 2021

Westwood Clinic is located in Westwood which is a residential area of the city of Peterborough, Cambridgeshire. The practice provides services for approximately 5,400 patients under a General Medical Services (PMS) contract commissioned by NHS Cambridgeshire and Peterborough Clinical Commissioning Group.

The practice is managed by two GP partners (1 male, 1 female) who are supported by clinical staff; two long term GP locums, a physician associate, two practice nurses and one healthcare assistant. The practice also employs a practice manager and a team of reception, clerical and administrative staff.

The practice opens between the hours of 8am and 6.30pm, Monday to Friday. Outside of practice opening hours patients are able to access pre-bookable evening and weekend appointments through a network of local practices. In addition to this, a service is provided by Herts Urgent Care, by patients dialling the NHS 111 service.

According to Public Health England information, the patient population has a slightly higher than average number of patients aged 18 and under compared to the average across England. It has a slightly lower number of patients aged 65 and over, aged 75 and over and aged 85 and over compared to the practice average across England. Income deprivation affecting children and older people is significantly higher than the practice average across England.

The practice is part of a wider network of GP practices with Ailsworth Medical Centre and Westwood Clinic.

Updated 10 November 2021

We carried out this announced inspection at Westwood Clinic on 14 October 2021. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Well-led – Good

Previously we carried out a comprehensive inspection of Westwood Clinic on 13 December 2018 when the practice was rated as inadequate overall.

We then carried out an announced comprehensive inspection on 9 July 2019 and took urgent action to suspend Westwood Clinic’s CQC registration and prevent the provider from delivering regulated activities.

We carried out a further comprehensive inspection on 13 August 2019 to follow up on the breaches of regulation. Following this inspection, we found the practice had made sufficient improvements to satisfy the suspension notice and therefore we lifted the provider’s suspension and the caretaking arrangement ceased.

We carried out an announced comprehensive inspection at Westwood Clinic on 21 January 2020. The practice was rated as requires improvement.

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

Why we carried out this inspection

This inspection was a focused inspection in relation to the breaches of regulations identified at our last inspection. The inspection focused on the following key questions:

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

The information we received and reviewed did not indicate the previous rating of good for providing caring and responsive services was affected and therefore these ratings are carried over.

How we carried out the inspection

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

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account 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:

• Requesting evidence from the provider and reviewing this.
• 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.
• Conducting staff interviews using video conferencing.
• Gaining feedback from staff by using staff questionnaires.
• Requesting and reviewing feedback from the Patient Participation Group.
• Requesting staff questionnaires
• 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:

• Safe and effective care was delivered to patients. The practice had made and sustained the improvements required to address the concerns identified in our last inspection.
• The practice had met the challenges of the COVID-19 pandemic, they had taken action to redesign, upgrade and ensure safe patient flow within the building. Staff were proud to have worked with the practice to continue to deliver care and treatment to patients.
• We found the practice had clear and effective systems to ensure patients prescribed medicines received regular monitoring in a timely manner.
• We found the practice system and process to ensure all medicines were linked to a diagnosis or particular problem was not always wholly effective.
• We found the practice system and process did not always ensure information for all patients with potential chronic kidney disease was recorded.
• The practice told us they were reviewing the quality of their care plans to ensure they were comprehensive and shared with the patients.
• The practice had agreed plans to address any backlogs such as the reviews for patients with long term conditions.
• The practice had developed the practice intranet to provide easy, current and relevant information to staff. Staff gave positive feedback.
• The practice had developed a post COVID-19 pandemic recovery action plan to review and improve their recall systems to ensure patients received appropriate routine reviews.

We did not find any breaches of regulations; however, the provider should:

• Implement and monitor the action plan to address the backlog of long-term condition reviews.
• Monitor the system to ensure all patient records are correctly coded, and that medicines are linked to diagnosis or problems within the clinical record.
• Monitor and embed the systems and processes newly implemented to ensure all patients taking high risk medicines are monitored appropriately.
• Continue to improve the system to ensure patient care plans are documented and in a format that is useful to patients and other health professionals.
• Continue to monitor and encourage patients/guardians to attend appointments for baby immunisation and cervical screening.

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