Westcroft Health Centre

Updated 5 January 2023

Westcroft Health Centre provides a range of primary medical services from its location at 1 Savill Lane, Westcroft, Milton Keynes, MK4 4EN. The telephone number is 01908 520545

and the practice website address is www.westcrofthealthcentre.com

Westcroft Health Centre is part of the Bedfordshire, Luton and Milton Keynes Integrated Care System. The practice holds a General Medical Services (GMS) contract for providing services, which is a nationally agreed contract between general practices and NHS England for delivering general medical services to local communities. The practice is a member of a local Primary Care Network.

The GP practice is registered with the Care Quality Commission under the Health and Social Care Act 2008 to provide the following regulated activities:

• Diagnostic and screening procedures
• Family planning
• Midwifery and maternity services
• Surgical procedures
• Treatment of disease, disorder or injury.

The practice serves a population of 15,378 patients. Information published by Public Health England shows that deprivation within the practice population group is in the ninth lowest decile (9 of 10). The lower the decile, the more deprived the practice population is relative to others. The practice population is largely white British, with less than 25% of the practice population being from Black and Minority Ethnicity backgrounds.

The clinical team consists of four GP partners, three salaried GPs, four advanced nurse prescribers, two practice nurses and a health care assistant. The team is supported by a business and finance manager, an operations manager and a team of administrative staff. The practice is a teaching and training practice and accepts GP registrars every year. (Registrars are fully qualified and registered doctors training to become general practitioners).

Westcroft Health Centre is open between 8am and 6.30pm Monday to Friday. Extended hours are provided by the practice every Tuesday and Thursday between 7am and 8am. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Updated 5 January 2023

We carried out an announced inspection at Westcroft Health Centre on 24 November 2022. Overall, the practice is rated as good.

We rated each key question as follows:

Safe - Requires improvement

Effective – Good

Well-led – Good

Following our previous inspection on 27 January 2020, the practice was rated Good overall and good for all key questions.

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

Why we carried out this inspection

This inspection was part of our inspection sampling programme for locations currently rated good. We carried out a focused inspection and this included a site visit. We inspected the safe, effective and well-led key questions.

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 found that:

• The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse in most cases.
• Appropriate standards of cleanliness and hygiene were not always met.
• There were adequate systems to assess, monitor and manage risks to patient safety in most cases.
• The practice’s systems for the appropriate and safe use of medicines, including medicines optimisation and the management of long-term conditions were not always comprehensive.
• The practice had a system to learn and make improvements when things went wrong. However, not all safety alerts had been acted on or appropriately reviewed.
• Patients’ needs were assessed and care and treatment was delivered in line with care pathways.
• There was a programme of monitoring the outcomes of care and treatment.
• The practice was able to demonstrate in most cases that staff had the skills, knowledge and experience to carry out their roles.
• Staff worked with other organisations to deliver effective care and treatment.
• Staff were consistent and proactive in helping patients to live healthier lives.
• People were able to access care and treatment in a timely way.
• The practice involved the public, staff and external partners to sustain high quality and sustainable care.
• The way the practice was led and managed promoted the delivery of high quality, person-centred care and an inclusive, supportive environment for staff. There was a focus on continuous learning and improvement at all levels of the practice. Where we identified any concerns during our inspection, the practice took immediate action to respond or plans of action were in place to ensure any issues were resolved.

We found breaches of regulations. The provider must:

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

The provider should:

• Continue to audit staff personnel files and take action to address gaps in practice recruitment procedures.
• Continue to manage and complete all appraisals in accordance with the practice policy.
• Continue to take action to increase the uptake of cervical screening and childhood immunisations.

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