The Care Quality Commission
  • Doctor
  • GP practice

Woodside Surgery Also known as Woodside Surgery

Overall: Good read more about inspection ratings

High Street, Loftus, Saltburn By The Sea, Cleveland, TS13 4HW (01287) 640385

Provided and run by:
Woodside Surgery

All Inspections

29 September 2022

During a routine inspection

We carried out an announced comprehensive inspection at Woodside Surgery on 29 September 2022. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

Following our previous inspection on 25 May 2021, the practice was rated as requires improvement overall and for the key questions of safe and well led, good for caring, effective and responsive. There had been significant improvements following our previous inspection on 24 September 2020, where the practice was rated as Inadequate overall and for the key questions of providing safe, and well-led care, but requires improvement for providing effective, caring and responsive services.

At this inspection we found the provider had continued to sustain and deliver further improvement. Changes which were still in their infancy in May 2021 had become more embedded, and the practice had developed a safety and improvement culture.

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

Why we carried out this inspection

We carried out this inspection to follow up on breaches of regulation from a previous inspection, and in line with our inspection priorities due to the previous overall requires improvement rating.

We inspected all five key questions and followed up on a previous breach relating to safeguarding systems and processes.

How we carried out the inspection/review

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A site visit.
  • Staff questionnaires.

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 found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • The practice was effective in proactively identifying carers
  • The monitoring of high-risk medicines, processes for safety alerts and overall medicines’ management was much improved. The provider had plans in place for identified areas for improvement.
  • The provider and practice team had worked hard to bring about significant improvements in the governance and safety of the practice.

Whilst we found no breaches of regulations, the provider should:

  • Improve the prescribing rates of pregabalin, gabapentin and benzodiazepines.
  • Ensure all staff receive their upcoming safeguarding training.
  • Improve the way in which governance systems such as risk assessments and policies are kept under review
  • Strengthen clinical audit programme to include a second cycle to monitor improvement to patient care and outcomes

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

25 May 2021

During a routine inspection

We carried out an announced inspection at Woodside Surgery on 25 May 2021. Overall, the practice is rated as Requires Improvement.

The ratings for each key question are:

  • Safe - Requires Improvement
  • Effective - Good
  • Caring - Good
  • Responsive - Good
  • Well-led - Requires Improvement

Following our previous inspection on 24 September 2020, the practice was rated as Inadequate overall and for the key questions of providing safe, and well-led care, but requires improvement for providing effective, caring and responsive services. We placed the practice into special measures and applied urgent conditions to the provider’s registration:

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

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on:

  • The key questions of Safe, Effective, Caring, Responsive, and Well-led.
  • Breaches of regulations and ‘shoulds’ identified in previous inspection.
  • Section 31 conditions applied to the provider’s registration.

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 and questionnaires.
  • 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 short 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 overall and for the key questions of are services safe, and well-led. With the exception of the population group ‘older people’ in the effective key question, all of the population groups in the effective key question and the responsive key question have been rated as Good. The key questions of; are services effective, caring and responsive have been rated as good.

We found that:

  • The provider had complied with the conditions imposed by the Care Quality Commission.
  • There were a number of policies and procedures that needed to be developed and embedded to support practice. Systems to safeguard vulnerable adults needed to be improved. The management and optimisation of medicines within the practice had improved since the last inspection, but further embedding and development of new processes was needed to ensure the overarching governance of medicines. Clinical coding of records had improved which contributed to effective searches of records and an improved culture of safety.
  • Clinical coding had significantly improved at the practice which led to better outcomes for patients in all these population groups. There was an increase in quality improvement activity. Effective care for patients with diabetes and high blood pressure needed to be improved further. Arrangements for end of life care and ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) needed some further improvement too.
  • Most staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • 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.
  • Systems for good governance were beginning to emerge and, in some cases, becoming embedded in practice. For example, systems to identify, manage and mitigate risks were in place and being actively used to monitor safety. This meant that the provider was developing a wider oversight of the running of the practice, which could contribute to improved care and treatment for patients. Some staff told us they did not always feel comfortable, or confident about the outcome, of raising concerns. Others told us there was a high level of support for this process.

We have now removed the conditions from the provider's registration.

We found a breach of regulations. The provider must:

  • Safeguard service users from abuse and improper treatment

However, the provider should:

  • Continue to monitor the competence of all clinicians at Woodside Surgery, engage in clinical supervision, prescribing supervision, one-to-ones and documented peer discussion.
  • Continue to audit consultation documentation to ensure appropriate clinical decisions are made, based on the information acquired, including referral, with a recording of the working diagnosis.
  • Continue to monitor Medicines and Healthcare products Regulatory Agency /Central Alerting System/ drug safety update alerts using its comprehensive search system that is run every month to contribute to safe systems.
  • Continue to ensure that appropriate reviews and monitoring are carried out for all patients when prescribing high risk medicines and other medicines that require monitoring at Woodside Surgery.
  • Review and update their infection prevention and control policies in line with the latest guidance and to reflect practices in place within the service

We have taken the service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

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

24 September 2020

During a routine inspection

We carried out an announced comprehensive inspection at Woodside Surgery between 24 September 2020 and 18 October 2020 as part of our inspection programme. This included obtaining some information from the practice virtually and included a site visit that took place on 24 September 2020.

We previously carried out an announced comprehensive inspection at Woodside Surgery in October 2019 as part of our inspection programme. The practice was rated inadequate, placed into special measures and warning notices in relation to safe care and treatment and good governance were issued. We carried out an announced unrated focused inspection at Woodside Surgery in February 2020 and found that the issues identified in the warning notices had begun to be addressed.

The full reports on the inspections carried out in October 2019 and February 2020 can be found by selecting the ‘all reports’ link for Woodside Surgery on our website at www.cqc.org.uk.

This announced comprehensive inspection in September 2020 looked at all of the key questions:

Is the service Safe?

Is the service Effective?

Is the service Caring?

Is the service Responsive?

Is the service Well led?

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.
  • Significant events and complaints were not always used to monitor trends and did not always drive improvement.
  • However, we saw evidence of new systems and processes for communication that had been developed since the previous inspection.
  • The practice’s quality improvement program did not reliably identify or respond to patients needs to ensure they received appropriate or proactive care in line with guidance. This was further impacted by inappropriate, incorrect or missing coding.
  • The practice did not evidence that learning was shared effectively and used to make improvements. We found learning from previous events was not taken forward and similar errors were repeated leading to significant patient safety concerns.

We have again rated this practice as inadequate overall.

We rated the practice as inadequate for providing safe, effective and well led services because:

  • We found the practice’s system for managing patient and drug safety alerts did not ensure medicines were prescribed safely. We found the practice had not properly actioned any of the four safety alerts we reviewed, which affected at least 48 patients. There was no evidence to show the practice had taken action to protect all of those patients from avoidable harm.
  • The practice did not evidence a safe system to ensure patients on high risk medicines were appropriately managed in a timely way. We reviewed seven high risk medicines and found that five were not appropriately managed, affecting at least 27 patients.
  • The practice did not fully evidence that patients had a structured and comprehensive medicine review. We identified reviews had been coded on the clinical system but there was no evidence in the clinical records of a structured medicine review or consultation with the patient. We reviewed patient consultation records and found discrepancies with the coding of medical records.
  • We reviewed the practice’s system for managing pathology results and found that there was not an effective system to ensure urgent abnormal results were always reviewed and acted on in a timely way.
  • The policy and procedures for recruiting new members of staff to the practice were ineffective. This had been subject to a requirement notice from the previous inspection in October 2019.
  • The practice failed to evidence patients’ needs were adequately assessed. We found care and treatment was not always delivered in line with current legislation, standards and evidence-based guidance
  • We found a number of examples where clinical coding was missing from patient records or the clinical coding applied was not accurate. The poor quality coding of patient records meant that patient’s needs were not always identified and therefore they were not always given appropriate care and treatment.
  • Due to the failings of the practice to ensure clear and accurate record keeping we were not assured care was effective for patients across all population groups.
  • The practice failed to have an effective system in place for recalling, monitoring or treating patients with a potential diagnosis of diabetes. This did not ensure these patients received proactive care and advice to make informed choices and life style changes to prevent further deterioration of their health.
  • We found a lack of leadership capacity and capability to successfully manage challenges and implement and sustain improvements. The GP partners failed to provide leadership to ensure effective and cohesive team working.
  • The practice could not evidence that risks, issues and performance were managed to ensure that services were safe or that the quality of those services was effectively managed. We found examples where patient care was of poor quality and the practice had failed to act.
  • We found a lack of governance and assurance structures and systems which led to significant patient safety concerns identified at this inspection.

We rated the practice as requires improvement for providing caring and responsive services because:

  • Patients were not always given timely and appropriate information about their care, treatment or condition.
  • The provider had not carried out its own patient survey in the last 12 months.
  • The provider did not always make contact with bereaved families.
  • End of life care arrangements needed to be improved overall.
  • Overall access to appointments was adequate and there were plenty of appointments available during Covid19.
  • The practice had successfully moved to a total triage model as a result of the pandemic.
  • The percentage of respondents to the GP patient survey who responded positively to ‘how easy it was to get through to someone at their GP practice on the phone’ was lower than the national average.
  • Complaints were not used to drive improvements at the practice.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • 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.

This is in accordance with the fundamental standards of care.

This service will remain in special measures. We are currently in the process of undertaking enforcement action against this provider. Once the appeal process has been concluded we will publish a supplementary report detailing the action taken.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration. Special measures will give people who use the service the reassurance that the care they get should improve.

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

14 february 2020

During an inspection looking at part of the service

We carried out an announced, comprehensive inspection of Woodside Surgery on 23 October 2019. We identified five breaches of regulations and issued warning notices for three of the breaches. This focused unrated inspection carried out on 14 February 2020 was to check whether the provider had taken steps to comply with the legal requirements for these three breaches. The three breaches of regulation we inspected against were for:

Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Safe care and Treatment.

Regulation 13 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Safeguarding Service Users from Abuse.

Regulation 17: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Good Governance.

The full comprehensive report on the Woodside Surgery inspection can be found by selecting the ‘all reports’ link for Woodside Surgery on our website at .

This inspection was an unannounced focused inspection carried out on 14 February 2020 to confirm that the service had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 23 October 2019.

This report covers our findings in relation to those requirements. Our key findings were as follows:

Improvements had been made with respect to patient safety, effectiveness and leadership following our last inspection on 23 October 2019. For example: New processes had been put in place to report and manage significant events and safeguarding concerns. Patient safety and medicines alerts were being received, assessed and when necessary, actioned appropriately. Improvements had been made with regard to effective governance and management within the service. For example, training and recruitment records were centrally recorded.

However, there was also an area of practice where the provider needed to make improvements: The provider should:

  • Continue to develop clinical policies and procedures and embed them within the delivery of care and treatment.

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.

On the day of our inspection the provider was able to demonstrate improvement in some of the areas where the inspection team had previously found that it was in breach of Health and Social Care Act (2008) regulations. The service is on a trajectory of development and improvement. The inspection team found on the day of inspection, 14 February 2020, that some of the risks highlighted in the warning notices issued to the provider had significantly reduced.

Special measures give people who use the service the reassurance that the care they get should improve. The service will still be kept under review and if needed could be escalated to urgent enforcement action. Another inspection will be conducted within a further four months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

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

23 October 2019

During a routine inspection

We carried out an announced comprehensive inspection at Drs M.S. Glasby, R.G. Dall'Ara, C.J. Rigby, R.C. Rigby & M.D. Speight (known as Woodside Surgery) on 23 October 2019 as part of our inspection programme. The provider registered with the Care Quality Commission on 1 April 2013. In July 2016 we carried out a comprehensive inspection of this location and rated it good overall, good for all key questions and good for all population groups.

On 23 October 2019, we decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions: Safe, Effective and Well led.

Because of the assurance received from our review of information we carried forward the ratings for the following key questions: Caring and Responsive.

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 now rated this practice as inadequate overall.

We rated the practice as inadequate for providing safe services because:

  • The practice did not have clear systems and processes to keep patients safe.
  • Receptionists had not been given guidance on identifying deteriorating or acutely unwell patients. They were not aware of actions to take in respect of such patients.
  • The practice did not have appropriate systems in place for the safe management of medicines.
  • The practice did not learn and make improvements when things went wrong.

We rated the practice as requires improvement for providing effective services because:

  • There was limited monitoring of the outcomes of care and treatment.
  • The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
  • Some performance data was below local and national averages.

We rated the practice as inadequate for providing well-led services because:

  • Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
  • While the practice had a clear vision, that vision was not supported by a credible strategy.
  • The practice culture did not effectively support high quality sustainable care.
  • The overall governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice did not always act on appropriate and accurate information.
  • We saw little evidence of systems and processes for learning, continuous improvement and innovation.

These areas affected all population groups, so we rated all population groups as requires improvement

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Safeguard service users from abuse and improper treatment.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure that statutory notifications are made to CQC, as soon as reasonably practicable to do so.

(Please see the specific details on action required at the end of this report).

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

5 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Woodside Surgery on 5 April 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • 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.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • There was the need to review and update a number of policies and procedures.

  • There was the need to develop and introduce a formal induction package for locum GPs.

  • A system needed to be fully implemented to ensure that the relevant professional eligibility to practice checks were routinely carried out.

  • A formal training matrix needed to be introduced and a system implemented to ensure that clinical staff were up to date with relevant clinical training.

  • Risk assessments needed to be developed to ensure on-going monitoring of risks to patients.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice