The Care Quality Commission
  • Doctor
  • GP practice

Woodside Surgery

Overall: Good read more about inspection ratings

Woodside Road, Boothtown, Halifax, West Yorkshire, HX3 6EL (01422) 557711

Provided and run by:
Caritas Health Partnership

All Inspections

20 and 21 June 2023

During a routine inspection

We previously carried out an announced focused inspection of Woodside Surgery (Caritas Health Partnership) on 30 and 31 March 2022. Following that inspection, the provider was rated requires improvement overall (inadequate in safe and requires improvement in effective and well-led). We issued a warning notice for breach of Regulation 12 (Safe care and treatment) and a requirement notice for breach of Regulation 17 (Good governance).

We then carried out an announced focused inspection on 11 and 12 July 2022 to check that the provider had complied with the Regulation 12 (Safe care and treatment) warning notice. At that inspection we found the provider had improved systems and processes to demonstrate safe and effective care and treatment. We did not review the previous ratings awarded to the provider at this inspection.

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

Why we carried out this inspection

This inspection was an announced, comprehensive, rated inspection carried out on 20 and 21 June 2023 to follow-up breaches of regulation from the previous rated inspection in May 2022.

Overall, the practice is now rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

How we carried out the inspection

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:

  • 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 shorter site visit.
  • Reviewing staff questionnaires.
  • Staff interviews.

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 that:

  • The provider had been responsive to the findings of our previous inspections and we found improvements in systems and processes to manage patient safety alerts, medicines monitoring, staff training and infection prevention and control.
  • There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
  • Patients received effective care and treatment that met their needs.
  • There was a programme of quality improvement, including clinical audit.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • The practice had made improvements to systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

  • Continue with the embedding of systems and processess to ensure the proper and safe management of medicines.
  • Continue to monitor and make improvements to increase the uptake of cervical screening and childhood immunisation outcomes.

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 Health Care

11 & 12 July 2022

During an inspection looking at part of the service

We previously carried out an announced focused inspection at Woodside Surgery (Caritas Group Practice) on 30 and 31 March 2022. The overall rating for the practice was requires improvement. The provider was rated inadequate for providing safe services and told they must improve.

The full report from the March 2022 inspection can be found by selecting the ‘all reports’ link for Woodside Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused (unrated) inspection, carried out on 11 and 12 July 2022.

Why we carried out this inspection

The purpose of this inspection was to review actions taken by the provider in response to a warning notice for non-compliance with Regulation 12 of the Health and Socia Care Act (Regulated Activities) Regulations 2014, safe care and treatment, issued by the Care Quality Commission in April 2022.

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

  • Completing clinical searches on the practice’s patient records system and discussing findings with 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.

This inspection did not receive a rating

We found that:

  • The practice had improved systems and processes to keep patients safe. Medicines management and prescribing processes had been reviewed and improved.
  • Patients with long-term conditions were appropropriately managed.
  • Systems for ensuring diagnostic coding on patients’ records were in place.
  • Infection prevention and control measures had been addressed. The clinical environments were clean and free from clutter.

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

  • Embed processes for maintaining oversight of test results and correspondence within the practice, to avoid any delays to patient care and treatment.

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

30 March 2022

During a routine inspection

We carried out an announced inspection at Woodside Surgery (Caritas Group Practice) on 30 and 31 March 2022. The inspection included both remote assessments and interviews, and a site visit. Overall, the practice is rated as requires improvement.

Set out the ratings for each key question

Safe - Inadequate

Effective – Requires improvement

Well-led – Requires improvement

Following our previous inspection on 23 October 2018 the practice was rated as good overall, with the key question of effective rated requires improvement. This was because we found gaps in relation to staff training and support arrangements. We returned to the practice on 20 June 2019 and found that the necessary improvements had been made, and the practice was rated as good for all key questions.

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

Why we carried out this inspection:

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in West Yorkshire. To understand the experience of GP providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system-wide feedback. We also included additional questions to establish the practice response to access to appointments for patients following the COVID-19 pandemic.

How we carried out the inspection/review

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
  • Question sheets sent to staff for completion prior to the inspection

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 Requires Improvement overall

We found that:

  • There were gaps in systems and processes to keep patients safe. Medicines management and prescribing processes were not effectively followed.
  • Diagnostic coding on patients’ records were not always in place.
  • Infection prevention and control measures were not implemented appropriately.
  • The practice had recently undergone significant staffing changes. A new leadership team was in place, and all staff vacancies had been filled or were due to be filled within the next few weeks.
  • Patients were able to access face to face or telephone appointments at any of the three sites provided by the practice.
  • Systems were in place to effectively share relevant information with out of hours and urgent healthcare providers.
  • Staff told us they were happy to work at the practice. They told us the senior team was approachable and supportive.

We found breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

  • Take steps to ensure that staff training is updated in line with recommended timescales, and maintain oversight of this.
  • Carry out risk assessments to provide rationale for stocks of emergency medicines not held.
  • Develop plans to improve immunisation uptake for pre-school children.

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

23 October 2018

During a routine inspection

We carried out an announced comprehensive inspection at Caritas Group Practice on 23 October 2018 as part of our inspection programme. Our inspection team was led by a CQC lead inspector. The team included a GP specialist adviser and a second CQC inspector.

Our judgement of the quality of care at this service is based 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.

I have rated this practice as good overall, however the key question of are services effective has been rated as requires improvement.

We concluded that:

  • There was an innovative model of care delivery in place. The service was nurse-led; with a range of clinical expertise provided by General Practitioners, Advanced Nurse Practitioners, Advanced Clinical Practitioners and Practice nurses, to deliver a holistic needs-led service.
  • There were clear incident reporting systems in place. When incidents did happen, the practice learned from them and improved their processes.
  • The practice was an accredited advanced training practice, providing training for undergraduate and post-graduate nurses, as well as medical students and other postgraduate clinicians.
  • The practice carried out quality improvement activity to monitor and review the effectiveness and appropriateness of the care it provided. Care and treatment was delivered according to evidence-based guidelines.
  • Staff described and demonstrated a caring and compassionate approach to treating patients.

However, we also found that:

  • There were substantial gaps in relation to uptake of mandatory training for staff, including fire safety and infection prevention and control training.
  • Induction processes were in place. However not all staff had received an appropriate or safe induction. Staff appraisals were also out of date at the time of our inspection.
  • Clinical communication systems were in place, however processes for disseminating clinical updates were not fully established in all cases.
  • Patients told us they were not always able to get an appointment when they needed one. The practice had recently reduced the opening times at two of their sites.

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

  • The service provider had failed to ensure that staff maintained their requirements in relation to mandatory training.
  • The service provider failed to provide an adequate induction and supervision process for new starters in all cases.
  • Staff appraisals were out of date at the time of our visit.
  • Systems for the dissemination of National Institute for Health and Care Excellence (NICE) guidelines and other clinical updates to staff were not clear in all cases.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

The areas where the provider should make improvements are:

  • Continue to review and evaluate their approach in relation to appointment availability for patients at all sites.
  • Develop and embed clear systems for dissemination of National Institute for Health and Care Excellence (NICE) guidelines and other clinical updates to staff.
  • Review staff immunisation status in line with Public Health England guidelines.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

22 April 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Woodside Surgery on 22 April 2015. Overall the practice is rated as good.

Specifically, we found the practice was good in providing safe, responsive, caring, well-led and effective care for all of the population groups it serves.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice