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Inspection carried out on 05 February 2019

During a routine inspection

We carried out an announced comprehensive inspection at Woodley Centre Surgery (and the branch surgery in Winnersh) on 5 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 good overall and good for all population groups.

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.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way because the appointment systems had been revised in the last 18 months.
  • The practice promoted the delivery of high-quality, person-centre care.
  • Monitoring of systems to ensure safe and effective provision of care were not always operated consistently.

We found two areas of outstanding practice:

  • The practice retained a register of at risk children who had de-registered from the practice. This enabled the practice to contribute to any safeguarding reviews for these patients.
  • Group consultations were held for patients with specific long term conditions. Patient feedback about these consultations was positive. Patients said they had a better understanding of their condition, how to manage it and use the experience of others with a similar condition as a motivation in their care.

However, we found a breach of regulation that led to a judgement that the practice requires improvement for provision of well led services the provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider could also make additional improvements and should:

  • Review the processes in place for following up invitations to take part in the cervical cancer screening programme. The uptake among patients eligible to take part in this screening was below the national target of 80%.

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

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

Inspection carried out on We have not revisited Woodley Centre Surgery as part of this review because they were able to demonstrate that they were meeting the standards without the need for a visit.

During a routine inspection

Letter from the Chief Inspector of General Practice

During our comprehensive inspection of Woodley Centre Surgery in April 2016 we found concerns relating to a legionella risk assessment with outstanding high risk actions. This led to a rating of requires improvement for the provision of safe services. The practice sent us an action plan describing how they planned to make changes to address the issues that led to our concerns.

In addition to the breach of regulation, we recommended improvements were made to shared learning from complaints and patient feedback regarding telephone access and GP care and treatment.

We carried out a desk top inspection on 20 December 2016 to ensure these changes had been implemented and that the service was meeting regulations. The rating for the practice has been updated to reflect our findings. We found the practice had made improvements in the provision of safe services since our last inspection on 20 April 2016 and they were meeting the requirements of the regulation.

Specifically, the practice had:

  • Carried out all works necessary to ensure risk of legionella were minimalised at both practice sites and were continuing to liaise with the landlord in relation to further maintenance and risk assessment work at the Woodley site.

  • There was an improvement in patient feedback from the GP national patient survey for telephone access and GP care and treatment. Both had increased by 3% and were now comparable with national averages.

  • The practice provided evidence they were discussing complaints at regular meetings and sharing the learning outcomes with staff. They were also involving the PPG in practice issues and were working with them towards a combined PPG/practice newsletter and patient feedback box.

We have updated the ratings for this practice to reflect these changes. The practice is now rated as good for the provision of safe services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 20 April, 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Woodley Centre Surgery on 20 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 well managed, with the exception of those relating to legionella.
  • 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 decisions about their care and 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, although this was not always shared with all staff.
  • 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 must make improvements are:

  • To undertake all actions as outlined in the Legionella risk assessments, for both practice sites, dated March 2015.

In addition, the provider should:

  • Share learning and outcomes from complaints with all staff and the patient participation group.

  • Review patient feedback and address concerns regarding telephone access and GPs involving patients in decisions about their care and treatment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice