Woodland Drive Medical Centre

We carried out an announced inspection at Woodland Drive Medical Centre on 16th and 25th May 2022. Overall, the practice is rated as Requires Improvement.

Ratings for the key questions inspected are:

Safe – Requires Improvement

Effective – Requires Improvement

Responsive – Inspected not rated. (The data and evidence we reviewed in relation to the responsive key question did not suggest we needed to review the rating for responsive at this time. Responsive remains rated as good.)

Well-led – Requires Improvement

We did not inspect the caring key question as part of this inspection so caring remains rated as good.

We last inspected the practice on 26 May 2021, to follow up on concerns we received about the service. This was undertaken using a pilot methodology for a remote GP focused inspection and therefore we could not rate or amend ratings for the practice at this time. However, we did identify a breach of regulations relating to governance. The practice had previously been rated as good following an inspection in February 2016.

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

Why we carried out this inspection

This inspection was a focused inspection to follow up on:

• A breach of regulations and recommendations identified in the previous inspection
• We reviewed the key questions safe, effective and well led.
• Additionally, we reviewed access arrangements in the responsive domain and the rating for this area has been carried forward from the previous inspection.

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 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 Requires Improvement

We found that:

• Some improvements had been made since our last inspection for example, in the management of high-risk medicines. However, other areas had not been fully addressed for example, processes to manage risk and we identified gaps in additional areas such as recruitment.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• Patients could access care and treatment in a timely way.
• The practice did not have clear systems, practices and processes to keep people safe and safeguarded from abuse. The practice had not always implemented systems and processes in areas such as recruitment, training and fire safety systems to keep people safe and safeguarded from abuse.
• The practice did not have adequate systems for the appropriate and safe use of medicines.
• Patients mostly received effective care and treatment that met their needs. However, the practice had not effectively monitored care and treatment of some patients with long term conditions.
• The practice was unable to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
• The overall governance arrangements were not always effective, and the practice did not have clear and effective processes for managing risks.
• There was limited evidence of systems and processes for learning, continuous improvement and innovation.

We found three breaches of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed and ensure specified information is available regarding each person employed.
• 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 provider should:

• Review and improve management and disposal of sharps bins and expired single use equipment stock.
• Consider provision of a second thermometer in the fridges used to store medicines.
• Review and improve the whistleblowing policy and procedure with the contact details of the Freedom to Speak up Guardian.
• Review and improve engagement with the patient participation group.

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