Woodlands Surgery at Eden House

We carried out an announced focussed inspection at Woodlands Surgery at Eden House on 7 January 2020 to follow up on a breach of regulation identified at a previous inspection in January 2019.

At the last inspection in January 2019, we rated the practice as requires improvement for providing safe services because:

• We found the process for managing and storing emergency medicines was not always effective, because despite monthly checks being recorded, on the day of the inspection we found one emergency medicine which was five months out of date.

At this inspection we rated the practice as good for providing safe services because sufficient improvements had been made since our last inspection including:

• The practice had implemented a medicines handling policy since our previous inspection and continued fortnightly checks. On a quarterly basis, the practice manager completed an audit and spot checks to ensure the fortnightly checks had been completed.

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

This practice is rated as Good overall. The practice was previously inspected in May 2015, where the practice was rated as Good overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Woodlands Surgery at Eden House on 21 November 2018 as part of our inspection programme.

At this inspection we found:

• The practice had appropriate systems to safeguard children and vulnerable adults from abuse.
• We found the process for managing and storing emergency medicines was not always effective.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• The practice had achieved a lower than average number of antibacterial prescription items prescribed per Specific Therapeutic group Age-sex Related Prescribing Unit.
• The practice’s uptake of cervical and breast cancer screening was below the local and national averages.
• Patients we spoke with and through comment cards received, spoke positively about the practice, the staff and the services offered.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• There was not an active patient participation group. The practice told us they were working to establish one.
• Administration and non-clinical staff were provided with a quarterly training morning. During this time, two GP partners operated the telephone lines to ensure all staff were provided with this opportunity.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

• Ensure that registers of patients, such as carers and health checks, are correctly coded.
• Review and encourage uptake of the national screening cancer programme.
• Review and improve the uptake of childhood immunisations where needed.
• Review and improve the number of carers that the practice identifies and supports.
• Continue to develop and encourage patient participation at the practice.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.