Background to this inspection
Updated
19 July 2018
West Barnes Surgery provides primary medical services in Kingston Upon Thames to approximately 7,300 patients and is one of 26 member practices in the NHS Kingston Clinical Commissioning Group (CCG). The practice operates under a General Medical Services (GMS) contract and provides a number of local and national enhanced services (enhanced services require an increased level of service provision above that which is normally required under the core GP contract).
The Indices of Deprivation rank Kingston upon Thames as the third least deprived local authority in London and on average people in Kingston have a longer life expectancy than elsewhere in London or England. The main ethnic minority groups in the borough are Indian/ British Indian (4%), Sri Lankan (2.5%), African (2.3%) and Korean (2.2%). The practice patient population is predominantly white British.
The practice is located in a converted residential building across three floors. The ground floor offers patient reception, waiting room, accessible facilities with baby change area and patient consultation and treatment rooms. The first floor provides administrative space, patient waiting area, staff facilities and further consultation rooms. The second floor provides staff meeting space and kitchen.
The practice clinical team consists of one part time and three full time GP partners, three regular locum GPs, one full time practice nurse, one full time health care assistant and one GP registrar. West Barnes Surgery is a GP training practice. The practice administrative team is led by the practice manager, supported by an assistant practice manager, senior receptionist and seven reception and administrative staff.
The practice opens its doors between 8am and 7pm Monday to Friday. Telephone lines are operational between 8.30am and 1pm and 2pm 6.30pm, with patients able to speak to a doctor for emergency enquiries through the automated telephone answering service. Appointments are available in one morning and one afternoon session Monday to Friday. The practice offers pre booked extended hours appointments from 7.30am to 8am on a Wednesday morning, between 6.30pm and 7pm on a Monday, Tuesday and Friday evening, and between 8am and 12pm on Saturday mornings. When the practice is closed, patients telephoning the practice are directed to contact the NHS 111 service.
The practice is registered as a partnership with the Care Quality Commission (CQC) to provide the regulated activities of: treatment of disease, disorder or injury; diagnostic and screening procedures; surgical procedures; family planning services; and maternity and midwifery services.
Updated
19 July 2018
We carried out an announced comprehensive inspection at West Barnes Surgery on 19 October 2017. The overall rating for the practice was Good, but the practice was rated as Requires Improvement in the safe domain. The full comprehensive report on the October 2017 inspection can be found by selecting the ‘all reports’ link for West Barnes Surgery on our website at www.cqc.org.uk.
Following the October 2017 inspection, the practice submitted an action plan, outlining what they would do to meet the legal requirements in relation to the breach of regulation 12 (Safe care and treatment), 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We undertook this announced focussed inspection on 15 June 2018 to check that the practice had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements.
Overall, the practice remains rated as Good, and is now rated as Good for the Safe domain.
Our key findings were as follows:
- During the previous inspection in October 2017, we found that the practice had failed to address some risks identified in their fire risk assessment. When we returned to the practice in June 2018 we found that all identified risks had been addressed.
- During the previous inspection, we found that the practice was unable to provide evidence to show that they had considered, and put plans in place to mitigate, some risks identified in their infection prevention and control (IPC) risk assessment. When we returned to the practice in June 2018 we saw evidence that a log of actions to address IPC risks was being kept, and that regular internal IPC audits were being conducted.
- During the previous inspection in October 2017 the practice was unable to demonstrate how they ensured that staff were aware of their responsibilities in respect of IPC. When we returned to the practice in June 2018 we found that staff were receiving regular IPC updates from the IPC lead and that all staff had attended formal IPC training.
- During the previous inspection in October 2017 we found that the practice had not implemented the regular water testing recommended following their Legionella risk assessment. When we returned to the practice in June 2018 we found that two of the three monthly water monitoring tests were being carried-out; however, one of the tests recommended had been overlooked.
- During the inspection in June 2018 we found that the practice had not considered the risks relating to the storage of liquid nitrogen.
- During the previous inspection in October 2017 we found evidence of patient test results which were awaiting review by a GP who was not scheduled to attend the practice until the following week. When we returned to the practice in June 2018 we saw evidence that a buddy system was in place amongst GPs to ensure that all test results were reviewed in a timely way during staff absence.
The areas where the provider should make improvements are:
- Complete all regular testing of their water system recommended by their Legionella risk assessment.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice