Woodside Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that staff protected people from avoidable harm and made sure care was delivered from environments that were clean and well maintained. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a system in place to report, record and investigate incidents, significant events and near misses. However, there were some areas requiring improvement.

We reviewed 5 complaints and found they had been acknowledged and investigated. Of these, 2 were closed. However, there was no documented evidence of the outcome of the investigation included within the final responses to the complainants. During feedback, leaders told us they had implemented a new complaints management system to strengthen oversight and monitoring of responses.

Leaders told us there were open forums where staff could raise concerns and feedback directly to them. Staff we spoke with understood how to report concerns.

At the time of the assessment, there were no complaints being considered by the Parliamentary and Health Service Ombudsman.

Incidents and learning events were discussed at clinical meetings. Meeting minutes were maintained to ensure staff who were not present were kept informed of discussions.

The practice collaborated with patients and healthcare partners to establish and maintain safe systems of care, where safety was actively managed and monitored. They ensured continuity of care, including when patients transitioned between different practices.

Systems were in place for processing information relating to new patients, supporting safe and efficient onboarding. Pathology results were managed by clinicians, with arrangements in place to ensure continuity of review and follow-up should the responsible clinician be unavailable for an extended period. However, these processes needed to be consistent with the practice’s own policy. For example, the practice's policy for managing pathology test results required a GP to review results on the same day or within 48 hours. On the day of the assessment, we found one test result had not been reviewed within the required timeframe. Leaders told us they would take immediate action and review the result that day.

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were in place where appropriate and were regularly reviewed to ensure they continued to meet patients’ needs and preferences.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The practice made sure there were enough staff. They worked together well to provide care that met people’s individual needs. However, leaders did not have sufficient oversight processes in place regarding the recruitment of staff and the maintenance of recruitment records. We found records relating to pre-employment checks were incomplete, with evidence missing for some staff, including references and immunisation status.

All GPs working at the practice were locums. The provider had no assurance process in place to ensure locum staff were up to date with their training. Following the assessment, the practice had a clinical meeting and provided evidence from the meeting minutes which stated locum GPs were required to provide confirmation of completed training and submit relevant training certificates.

The practice employed a range of clinical and non-clinical staff, including GPs, an advanced clinical practitioner (ACP), a pharmacist, and an administrative team. At the time of the assessment, recruitment for several roles was underway to support service delivery.

There was a system to monitor mandatory training to ensure permanent staff completed the necessary updates. We found training was up to date and a system in place for appraisal. Staff described a supportive culture and opportunities for clinical discussion and learning.

The practice assessed the risk of infection. However, they did not always detect and control the risk of it spreading. The infection prevention and control (IPC) lead post had been vacant since October 2023. During this period, responsibility for the role was initially undertaken by the previous practice manager, and more recently covered by the operations manager. Following the assessment, the practice told us they had recruited a practice nurse who would undertake the role of IPC lead.

During the assessment, we found toiletries such as toilet paper were not available in the patients' toilet. Leaders explained supplies were not routinely provided because they frequently went missing. However, this had not been identified within the risk assessment, and there was no documented mitigation outlining how the practice managed the impact of this on patients.

The practice had a cleaning schedule available, which outlined how staff should clean the building. During our assessment, the practice's premises were noted to be visibly clean. Regular IPC audits were completed.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.