The Care Quality Commission
  • Doctor
  • GP practice

Woodlands Surgery

Overall: Good read more about inspection ratings

5 Woodlands Road, Redhill, Surrey, RH1 6EY (01737) 761343

Provided and run by:
Dr R Adams and Partners

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Woodlands Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Woodlands Surgery, you can give feedback on this service.

3 November 2022

During an inspection looking at part of the service

We carried out an announced inspection at Woodlands Surgery from 1 – 4 November 2022 Overall, the practice is rated as Good

Safe - Good

Effective - Good

Caring – Good (carried over from last inspection)

Responsive – Good (carried over from last inspection)

Well-led - Good

Following our previous inspection in September 2021 the practice was rated Requires Improvement overall and for the key questions Safe, Effective and Well Led. The data and evidence we reviewed in relation to the caring and responsive key questions as part of this inspection did not suggest we needed to review the rating at this time. This inspection included aspects of the responsive key question in relation to access only.

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

Why we carried out this inspection

The practice had been previously rated as Requires Improvement in September 2021. This inspection was to follow up breaches of regulations 12, 17 and 18 as identified in our previous inspection.

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
  • 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 Good overall

We found that:

  • The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse.
  • There were adequate systems to assess, monitor and manage risks to patient safety.
  • The practice had systems for the appropriate and safe use of medicines, including medicines optimisation.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
  • 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.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • There were evidence of systems and processes for learning, continuous improvement and innovation.
  • Staff had received the required immunisations which was centrally recorded.
  • All staff had completed their mandatory training.
  • Recent infection prevention control audits had been conducted. The practice was clean, well-organised with any expiry dates being reviewed and recorded.
  • Risks from audits were well managed and actioned in a timely manner.

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

  • Review and continue to monitor cervical smear screening to meet the Public Health England screening rate target.
  • Review and improve child immunisation rates to meet World Health Organisation (WHO) targets.
  • Continue to review and improve patient access.
  • Continue to take action to increase membership for the patient participation group

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

23 September 2021

During a routine inspection

We carried out an announced inspection at Woodlands Surgery on 22 September 2021 Overall, the practice is rated as Requires Improvement.

The key questions are rated as

Safe - Requires Improvement

Effective – Requires Improvement

Caring - Good

Responsive - Good

Well-led - Requires Improvement

Following our previous inspection in February 2019 the practice was rated Requires Improvement overall and for the safe, effective and well led key questions. Caring and responsive were rated as good.

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

Why we carried out this inspection

The practice had been previously rated as Requires Improvement in February 2019. This inspection was to follow up breaches of regulation 12, 17, 18, and 19 as identified in our previous inspection.

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
  • 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 requires improvement for all population groups.

We rated safe as Requires Improvement due to the insufficient improvements made from the previous inspection.

We rated the practice Requires Improvement for providing safe care because:

We found the practice had responded to some of the issues raised at the previous inspection. For example, managing patients on high risk medicines, Disclosure and Barring Service (DBS) checks undertaken for all staff, monitoring and recording the registration status of clinical staff, tracking prescription forms and pads throughout the practice. However, we found repeated breaches at this inspection. For example, there was insufficient monitoring of a small number of patients who were prescribed specific medicines, the practice was failing to follow up a small number of abnormal test results and there was a lack of monitoring of staff immunisations. We found infection control concerns that were not picked up in the infection control audit. The results from the fire risk audit, and electrical installation condition report were not always actioned in a timely manner.

We rated the practice Requires Improvement for providing an effective service because:

The practice had made some improvements in staff training. However, there were still gaps in training, including safeguarding and fire safety.

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

We rated the practice Requires Improvement for providing a well-led service because:

Although we found the provider had made some improvements, there were still breaches of regulation found. Some governance systems remained ineffective and leaders had insufficient oversight in order to identify when processes were not working as intended. The leaders in the service were unaware that some of the repeated risks identified at the last CQC inspection had not been resolved adequately.

We rated the practice Good for providing caring and responsive services because:

Patients received care and treatment that met their needs. Staff dealt with patients with kindness and respect and involved them in decisions about their care. The practice organised and delivered services to meet patients’ needs. The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • 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.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

The areas where the provider should make improvements are:

  • Review how gaps in employment are recorded
  • Review the frequency of clinical supervision
  • Review equipment cleaning logs to specify equipment and the frequency of recording when equipment is cleaned
  • Review and continue to monitor cervical screening to meet the Public Health England screening rate target.

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

26 Feb 2019

During a routine inspection

We carried out an announced comprehensive inspection at Woodlands Surgery on 26 February 2019 as part of our inspection programme.

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.

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

  • The practice could not demonstrate that they always carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • Infection prevention and control (IPC) was not always well managed.
  • Risk assessments had not all been completed and actions followed up as a result.
  • Evidence of shared learning and completion of actions as a result of significant events and safety alerts were not always well documented.
  • The practice did not always have systems for the appropriate and safe use of medicines.

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

  • There were gaps in staff training, including modules that had expired and those that had not yet been completed.

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

  • Governance arrangements were not always clear or well documented. For example, the practice did not have a business plan to support their priorities.
  • The practice did not always follow their own policies and they were not always consistent or up to date with current processes.
  • The practice did not have clear and effective processes for managing risks, issues and performance.

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

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

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice supported patients who were carers and had allocated a member of staff as a carers lead.
  • Patients found the appointment system easy to use and reported that they were mostly able to access care when they needed it.
  • The practice offered services to meet patients’ needs. The practice had number of young patients with learning disabilities living in local community homes. They reviewed those patients’ needs with their carers regularly and organised yearly health checks.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • 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.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

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

The areas where the provider should make improvements are:

  • Strengthen the processes in place to document the ongoing monitoring and actions in response to concerns about vulnerable patients.
  • Review the premises and facilities provided and ensure all reasonable adjustments are made, including that all patients can raise an alarm if they require assistance.
  • Continue to monitor practice performance in relation to antibiotic prescribing and child immunisation uptake rates.

Details of our findings

At this inspection we found:

  • We received positive feedback from patients who said they were treated with compassion, dignity and respect. They commented that they were involved in their care and decisions about their treatment.
  • There were processes to identify, understand, monitor and address current and future risks including risks to patient safety. However, some of these processes were not implemented effectively. For example; recruitment processes and ongoing monitoring of clinical registration, oversight of staff vaccinations, completion of risk assessments and subsequent action, infection control, medicines management including oversight of high risk and controlled drugs prescribing, learning and actions resulting from significant events, and safety alerts.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients found the appointment system easy to use and reported that they were mostly able to access care when they needed it.
  • 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. All staff spoke positively about working at the practice.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

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

5 September 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Woodlands Surgery on 11 October 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for Woodlands Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 5 September 2017 to confirm that the practice 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 11 October 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Good.

Our key findings were as follows:

  • The practice had ensured that oxygen was available to deal with medical emergencies.

  • The practice had ensured that recruitment arrangements included all necessary employment checks for all staff, including locums.

  • The practice had ensured that all practice specific policies and procedures were in place and up to date.

  • The practice had ensured that learning from all complaints and safety incidents was shared appropriately to support improvement.

  • The practice had ensured that action plans had been appropriately implemented in relation to infection control and legionella risk assessments.

  • The practice had taken action to ensure the nursing team were formally involved in clinical team meetings.

  • The practice had taken action to increase the uptake for cervical screening by employing an additional nurse and making contact with eligible patients.

  • The practice had implemented a new system to improve telephone access, demonstrating improved patient satisfaction in the national GP patient survey (from 66% to 78% of patients finding it easy to get through by phone).

The practice had reviewed the practice website to ensure that information for patients was up to date.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

11 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Woodlands Surgery on 11 October 2016. Overall the practice is rated as requires improvement.

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

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The GPs ran personal lists which gave continuity of care and provided clear responsibility for patient care and treatment.
  • 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.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events although we noted that the learning was not always shared widely enough to support improvement.
  • Risks to patients were assessed and managed with the exception of recruitment checks, the implementation and monitoring of actions identified by risk assessments, equipment available on site to deal with medical emergencies and practice policies.
  • Information about services and how to complain was available and easy to understand, although we noted that it was not easily accessible to patients. 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 the GP of their choice 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 provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Ensure that oxygen is available to deal with medical emergencies.
  • Ensure recruitment arrangements include all necessary employment checks for all staff.
  • Ensure that all practice specific policies and procedures are in place and up to date.
  • Ensure that all complaints and safety incidents are investigated thoroughly and that learning is shared appropriately to support improvement.
  • Ensure that clear actions plans are put in place and implemented as identified. For example infection control and legionella risk assessments.

The areas where the provider should make improvement are:

  • Consider how the nursing team could be integrated into the clinical team, for example regular attendance at clinical meetings.
  • Review and increase uptake for cervical screening.
  • Continue to monitor and improve telephone access to the practice.
  • Review practice website to ensure that information for patients is up to date.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice