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Inspection carried out on 20 June 2019

During an inspection looking at part of the service

Review carried out on 12 April 2019

During an annual regulatory review

We reviewed the information available to us about Woodside Surgery on 12 April 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 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

Inspection carried out on 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