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Inspection Summary

Overall summary & rating


Updated 3 September 2019

This provider is 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 on 23 July 2019 as part of our inspection programme. This was the first inspection of the provider since services commenced in September 2018.

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.

At this inspection, we found that:

  • The provider had established systems to ensure appointments that had been booked were appropriate to the service.
  • Patients received effective care and treatment that met their needs.
  • Patients had timely access to initial assessment, diagnosis and treatment. Patients did not have long waiting times to be seen by the healthcare professional.
  • Patients told us they valued the service, were involved in care and treatment decisions and did not have long waiting times.
  • Staff told us morale was high and they felt well supported by the management team.
  • The provider had a realistic strategy and supporting business plans to achieve its priorities.

We rated the provider as Requires Improvement for providing Safe services because:

  • We found high-risk medicines had been prescribed to one patient without evidence of up-to-date blood monitoring results for the patient.
  • The provider did not have complete oversight of all building and safety risk assessments for all of the premises used to deliver services. In addition to this, where a risk assessment had been completed, the provider did not have oversight of the progress of the actions required.
  • The provider did not have oversight of references for zero hour contract staff.
  • The provider did not evidence that learning outcomes from safety events were shared across the whole staff team.

We rated the provider as good for providing effective, caring, responsive and well-led services.

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.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider should make improvements are:

  • Continue to develop quality improvement activity to monitor and improve the quality of care offered to patients.
  • Review and improve the system for reviewing competency of staff employed.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas


Requires improvement



Updated 3 September 2019

We rated the provider as Good for providing Effective services.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance.

  • The provider assessed needs and delivered care in line with relevant and current evidence-based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis
  • We saw no evidence of discrimination when making care and treatment decisions.
  • The provider had a system in place to deal with repeat patients who may be overusing the service. However, at the time of the inspection this had not been needed.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The provider was actively involved in quality improvement activity.

  • The provider used information about care and treatment to make improvements.
  • For example, the provider had completed an audit of antibiotic prescribing to ensure this was completed in line with national guidelines. The results of the audit showed that in 159 consultations there were 10 prescriptions for antibiotics. Of these prescriptions, the provider found that all were appropriately prescribed and had clear clinical records to evidence the reasons why.
  • At the time of the inspection the provider had only been providing services for ten months so there was limited evidence of two-cycle audits. The provider told us they planned to carry out additional audits when more data was available.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC) or Nursing and Midwifery Council and were up to date with revalidation
  • Staff whose role included reviews of patients with long term conditions had received specific training and could demonstrate how they stayed up to date.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. For example, following their consultation, a letter including details of treatment given or onwards referral was sent to the patient’s own GP.
  • Before providing treatment, GPs at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history.
  • To be able to have an appointment at the extended hours service, all patients had to consent to sharing their medical records. This gave clinical staff had access to their full medical records to ensure safe and effective treatment.
  • The provider had risk assessed the treatments they offered. They had identified services which were not appropriate to offer at the time of the inspection due to the governance systems not being in place. For example, immunisations and vaccinations.
  • Care and treatment for patients in vulnerable circumstances was coordinated with other services.
  • Patient information was shared appropriately and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice so they could self-care.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their regular practice for additional support.

Consent to care and treatment

The provider obtained consent to care and treatment in line with legislation and guidance.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The provider monitored the process for seeking consent appropriately.



Updated 3 September 2019

We rated the provider as Good for providing Caring services.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The provider sought feedback on the quality of clinical care patients received.
  • The provider had received 2,866 patient satisfaction surveys from 18,223 patients (16% completion rate) since commencing services in September 2018; 98.9% of patients said they would recommend the service to friends and family.
  • Feedback from patients was positive about the way staff treat people. We received 54 CQC comment cards from patients; 53 of these were wholly positive about the service and one card was mainly positive with one negative comment which had been dealt with by the provider as a complaint.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The provider gave patients timely support and information.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Interpretation services were available for patients who did not have English as a first language. We saw notices in the reception areas, informing patients this service was available.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • Staff communicated with people in a way that they could understand, for example, communication aids were available.

Privacy and Dignity

The provider respected patients’ privacy and dignity.

  • Staff we spoke with recognised the importance of people’s dignity and respect.
  • Staff we spoke with knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.



Updated 3 September 2019

We rated the provider as Good for providing Responsive services.

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs.
  • The facilities and premises were appropriate for the services delivered. The provider delivered services from four locations at the time of inspection. These locations were chosen due to their geographical location and ensuring access was available for patients across the county.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately. The provider had audited the waiting times and found that patients on average waited four minutes to be seen for their appointment.
  • Patients with the most urgent needs had their care and treatment prioritised. The service provided was not an emergency service and patients were informed of this but staff recognised and prioritised any patients that was more unwell. However, where patient’s health deteriorated whilst waiting for their appointment, we saw evidence the provider prioritised these patients.
  • Patients reported that the appointment system was easy to use. Patients were booked appointments by their regular GP practice or via 111. The management team had worked with the local 111 service and provided them with a skill mix of staff available through the service. This was to ensure appropriate bookings of appointments.
  • The provider audited the appointments booked to ensure they were appropriate for the services delivered. If the provider found an inappropriate appointment booking, systems were in place to contact the practice responsible and advise them of this.
  • Referrals and transfers to other services were undertaken in a timely way.

Listening and learning from concerns and complaints

The provider took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff we spoke with told us they treated patients who made complaints compassionately.
  • Following a complaint, the provider acted to improve the quality of care. We saw learning from complaints was distributed to those involved in the complaint.



Updated 3 September 2019

We rated the provider as Good for providing Well-led services.

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • The leadership team consisted of a board of directors and a senior management team.
  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

The provider had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision; “to protect General Practice and develop Primary Care in order to provide the best possible care for our patients”.
  • The provider had a realistic strategy and supporting business plans to achieve its priorities.
  • The provider developed its vision and strategy jointly with staff and external partners such as the practices involved in the network.
  • The provider monitored progress against delivery of the strategy and reported back to the board of directors on the performance.


The provider had a culture of high-quality sustainable care.

  • Staff we spoke with felt respected, supported and valued. They were proud to work for the service. Staff we spoke with told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were positive relationships between staff and teams.
  • The provider focused on the needs of patients.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • At the time of the inspection, the service had been operating for approximately ten months and therefore there was limited evidence of staff appraisals and further development. However, the provider told us there was a plan in place to address this.

Governance arrangements

There were responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities.
  • Leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

  • There was processes in place to identify, understand, monitor and address current and future risks including risks to patient safety. However, we found the provider did not always have oversight of building and safety risk assessments relevant to locations where services were delivered from.
  • The provider had an informal process to monitor the performance of clinical staff. The provider told us they would formalise this process to demonstrate competence through audit of their consultations, prescribing and referral decisions.
  • Leaders had oversight of safety alerts, incidents, and complaints.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The provider acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. The provider completed a number of audits to assess appointment availability and suitability.
  • Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant governance meetings.
  • The provider used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The provider submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The provider involved patients, the public, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture.
  • Staff could describe to us the systems in place to give feedback. We saw evidence of feedback opportunities for staff.
  • The provider was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There was some evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement. We saw the provider had completed a number of initial clinical and non-clinical audits. The provider told us these audits would be continued and two-cycle audits would be completed.
  • The provider made use of internal and external reviews of incidents and complaints. However, the provider could not evidence learning was shared across the whole staff team.