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Inspection carried out on 23 Jul 2019

During a routine inspection

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