West Hoe Surgery

Updated 4 August 2022

West Hoe Surgery is located in Plymouth at:

2 Pier Street,

Plymouth,

Devon,

PL1 3BS

The West Hoe Surgery practice provides NHS GP services to adults and children. The practice offers services from one main practice.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.

The practice is owned by Partnership West Hoe Surgery and as a condition of registration has a person registered with the Care Quality Commission as the registered manager.

The practice team includes three GP Partners, three Salaried GPs, one regular locum, one GP registrar, one clinical pharmacist, one pharmacy technician, four Practice Nurses, four Health Care Assistants and one Practice Manager. The GPs are supported at the practice by a team of ten reception/administration staff. The practice has approximately 5,500 registered patients.

The West Hoe Surgery location on Pier Street is a new purpose built two-storey building with eight consultation rooms and two treatment rooms. For improved access the provider has installed an elevator, automatic entrance doors, and an accessible toilet on the ground floor.

The provider is a training facility for junior doctors and had installed a training room at the practice to enable staff to undertake further learning and development on-site.

There is limited parking available to service users but there are multiple machine payable parking spaces directly outside the premises. There are disabled bays available on the road.

The practice is part of a wider network of GP practices, the Waterside Health Network, Primary care network (PCN) which is made up of seven GP practices. PCNs provide proactive, coordinated care to their patients, in different ways to match different people’s needs, with a strong focus on prevention and personalised care.

Information published by Public Health England shows that deprivation within the practice population group is in the second lowest decile (two out of 10). The lower the decile, the more deprived the practice population is relative to others. According to the latest available data, the ethnic make-up of the practice area is 92% white, 2% Asian and 5% Other.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered an appointment.

Extended access is provided locally where late evening and weekend appointments are available. Out of hours services are provided by an external provider.

Updated 4 August 2022

We carried out an announced inspection at West Hoe Surgery on 23 June 2022. Overall, the practice is rated as good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

The practice has not been inspected since registration of the new location. The service had been registered at a previous location, but this has now been deregistered.

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

Why we carried out this 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 facilities.
• Speaking with staff during the visit to the practice.
• 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 staff questionnaire.
• 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
• information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall

We found that:

• The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse. Staff had the information they needed to deliver safe care and treatment and the practice learned and made improvements when things went wrong.
• There were adequate systems to assess, monitor and manage risks to patient safety and appropriate standards of cleanliness and hygiene were met.
• The practice had systems for the appropriate and safe use of medicines. Ongoing monitoring was being maintained with actions taken to follow up late reviews.
• Patients’ needs were assessed, and care and treatment were delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools. The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
• The practice was able to demonstrate that staff had the skills, knowledge and experience to carry out their roles. Staff worked together and with other organisations to deliver effective care and treatment.
• The practice always obtained consent to care and treatment in line with legislation and guidance.
• Staff treated patients with kindness, respect and compassion. Feedback from patients was positive about the way staff treated people. The practice respected patients’ privacy and dignity.
• People were able to access care and treatment in a timely way. The practice organised and delivered services to meet patients’ needs. Complaints were listened and responded to and used to improve the quality of care.
• There was effective leadership at all levels. Leaders demonstrated that they had the capacity and skills to deliver high quality sustainable care. The practice had a clear vision to provide high quality sustainable care and had a culture which drove high quality sustainable care
• There were clear responsibilities, roles and systems of accountability to support good governance and management and clear and effective processes for managing risks, issues and performance.
• The practice involved the public, staff and external partners to sustain high quality and sustainable care. There were systems and processes for learning, continuous improvement and innovation.

We saw the following outstanding practice:

• A proactive approach was taken to working with other organisations to improve care outcomes. The practice looked at innovative ways to develop the practice and worked with other services to improve care pathways and optimise patient experience. This included respiratory and diabetes management.
• People could access services and appointments in a way and at a time that suited them. The GP survey reports, while from 2021 showed that the response to patients calls and access to appointments increased the positive experience for patients.
• The service was supportive and inclusive in its role to identify and proactively address challenges and meet the needs of the population. The practice was creative and inclusive in its work during the pandemic with the homeless community and vulnerable adults.

Whilst we found no breaches of regulations, the provider should:

• Consider maintaining a record of prospective staff interviews. This would enable a point of reference.
• Date and sign all sharps bins at the start of use. This will enable an audit trail of use.
• Continue to increase the uptake of cervical screening for eligible patients.

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