The Westway Surgery

Updated 3 May 2022

The Westway Surgery is a GP practice located in the London Borough of Hammersmith and Fulham. Services are provided from 13 Westway, Shepherds Bush, London, W12 0PT. The practice operates from an adapted residential building. The surgery has good transport links and there is a local pharmacy located nearby. The practice is registered with the CQC to provide the regulated activities: diagnostic and screening services; maternity and midwifery services; and treatment of disease, disorder or injury. The practice operates under a General Medical Services (GMS) contract and provides services to approximately 3,742 patients. The practice is part of North West London Clinical Commissioning Group (CCG). The provider is registered as a partnership comprising of a GP partner and a managing (non-clinical) partner. There are two GPs (long term locums), a practice nurse, a healthcare assistant, a practice manager, a business manager and a team of administrative and reception staff. The practice is open from Monday to Friday from 8am to 6:30pm and patients can book evening and weekend access to appointments at three local surgeries. The practice has pre-bookable practice nurse appointments on Saturdays. The practice is affiliated with a Primary Care Network (PCN). According to the latest data available, the ethnic make-up of the practice is 50% White, 18.9% Black, 14% Asian, 10.5% Other ethnic groups and 6.5% Mixed. Information published by Public Health England rates the deprivation within the practice population as three, on a scale of one to ten. Level one represents the highest level of deprivation and ten the lowest. The majority of the practice demographic is people of working age.

Updated 3 May 2022

We carried out an announced focused inspection at The Westway Surgery, with remote clinical interview on 7 March 2022 and site visit on 9 March 2022. Overall, the practice is rated as good.

Set out the ratings for each key question

Safe - Good

Effective – Requires improvement

Caring – Not inspected

Responsive – Not inspected

Well-led - Good

Following our previous inspection on 7 December 2022, the practice was rated requires improvement overall and specifically for the key questions whether the practice was providing safe, effective and well-led care. We rated the practice as good for providing caring and responsive services.

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

Why we carried out this inspection

This inspection was a focused inspection to follow up on whether:

• Care and treatment was being provided in a safe way to patients.
• There were effective systems and processes in place to ensure good governance in accordance with the fundamental standards of care.

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:

• 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

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 have rated this practice as good for providing safe services because:

• The practice had clear systems, practices and processes to keep people safe from abuse.
• The practice held regular internal meetings to discuss the care of patients, including safeguarding concerns and care of vulnerable patients.
• The practice now had an effective system in place to implement patient safety alerts.
• The practice had put in place systems to manage patients on high risk medicines, however, we found a small number of patients on novel oral anticoagulants (NOACs) who had not had monitoring within the specified timeframes.
• The premises were well managed and there were effective systems for managing staff and training records.
• Emergency medicines and equipment on site were organised, in date and effectively managed.

We have rated this practice as requires improvement for providing effective services because:

• We identified some issues with the monitoring of long-term conditions, in particular the management of patients receiving treatments (inhaled therapies or rescue treatments) for respiratory disorders.
• The practice’s uptake for cervical screening remained below the 80% coverage target for the national screening programme, however there had been an increase of 10% since the last inspection in December 2020 and the practice had put in place systems to address barriers to the uptake of screening.
• The practice had not met the minimum 90% uptake for all five of the childhood immunisation uptake indicators, or the WHO based national target of 95%. There was an upward trend in the uptake of childhood immunisations since March 2019 in relation to three of the indicators. The practice had started to put in place systems to address barriers to the uptake of childhood immunisations.
• The practice had worked towards providing effective care for patients during the Covid-19 pandemic.
• The practice was proactive in helping patients to live healthier lives. The practice held weekly walking and running clubs for patients, with staff dedicating their lunchtimes and personal weekend time to these activities.

We have rated this practice as good for providing well-led services because:

• The practice had made improvements in providing well-led services in relation to good governance. It had implemented systems and processes in response to the findings of our previous inspection.
• The practice had effective processes to develop leadership capacity and skills. The practice had supported its practice manager in completing a management course in 2021 and was working towards a succession plan.
• The practice strongly encouraged personal development and learning amongst staff and was supportive in staff undertaking appropriate learning for their roles and in their future aspirations.
• We received feedback from the Patient Participation Group (PPG) that the practice was responsive in listening to patients and acting on feedback to make improvements.
• Staff members spoke positively about their employment at the practice and felt supported.

We found breaches of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition to the above, the provider should:

• Continue to monitor patients on high risk medicines in line with clinical guidance.
• Improve childhood immunisation uptake to bring in line with WHO targets.
• Improve cervical screening uptake to bring in line with the target for the national screening programme.

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