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Woodlands Surgery at Eden House Good

This service was previously registered at a different address - see old profile


Review carried out on 26 February 2020

During an annual regulatory review

We reviewed the information available to us about Woodlands Surgery at Eden House on 26 February 2020. 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 7 January 2020

During an inspection to make sure that the improvements required had been made

We carried out an announced focussed inspection at Woodlands Surgery at Eden House on 7 January 2020 to follow up on a breach of regulation identified at a previous inspection in January 2019.

At the last inspection in January 2019, we rated the practice as requires improvement for providing safe services because:

  • We found the process for managing and storing emergency medicines was not always effective, because despite monthly checks being recorded, on the day of the inspection we found one emergency medicine which was five months out of date.

At this inspection we rated the practice as good for providing safe services because sufficient improvements had been made since our last inspection including:

  • The practice had implemented a medicines handling policy since our previous inspection and continued fortnightly checks. On a quarterly basis, the practice manager completed an audit and spot checks to ensure the fortnightly checks had been completed.

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

Inspection carried out on 21 Nov 2018

During a routine inspection

This practice is rated as Good overall. The practice was previously inspected in May 2015, where the practice was rated as Good overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Woodlands Surgery at Eden House on 21 November 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse.
  • We found the process for managing and storing emergency medicines was not always effective.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • The practice had achieved a lower than average number of antibacterial prescription items prescribed per Specific Therapeutic group Age-sex Related Prescribing Unit.
  • The practice’s uptake of cervical and breast cancer screening was below the local and national averages.
  • Patients we spoke with and through comment cards received, spoke positively about the practice, the staff and the services offered.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • There was not an active patient participation group. The practice told us they were working to establish one.
  • Administration and non-clinical staff were provided with a quarterly training morning. During this time, two GP partners operated the telephone lines to ensure all staff were provided with this opportunity.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

  • Ensure that registers of patients, such as carers and health checks, are correctly coded.
  • Review and encourage uptake of the national screening cancer programme.
  • Review and improve the uptake of childhood immunisations where needed.
  • Review and improve the number of carers that the practice identifies and supports.
  • Continue to develop and encourage patient participation at the practice.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection carried out on 19 May 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Woodlands Surgery at Eden House on 19 May 2015. The overall rating for this practice is good. We found the practice to be good for providing safe, effective, caring, responsive and well-led services. The quality of care experienced by older people, by people with long term conditions and by families, children and young people is good. Working age people, those in vulnerable circumstances and people experiencing poor mental health also receive good quality care.

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

  • The practice was a friendly, caring and responsive practice that addressed patients’ needs and that worked in partnership with other health and social care services to deliver individualised care.
  • 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.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • 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.
  • The practice had very 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.

We saw several areas of area of outstanding practice:

  • We were told that the lead GP for safeguarding provided their personal contact details to patients with safeguarding concerns. This provided a continuity of care for those requiring this, for example children subject to child protection plans and their next of kin.
  • Staff were appointed regular protected training time, if staff were unable to undertake this for unforeseen reasons they would be paid overtime to attend.
  • The practice offered additional well being services to patients from its premises. For example yoga and pilates. This was beneficial for patients' wellbeing.
  • The practice offered new patient information evenings.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider should :

  • Improve the arrangements for undertaking appraisals of staff, namely the nursing staff.
  • Ensure staff files are complete and up to date, including appropriate pre-employment checks.
  • Ensure continuous recording of health and safety matters, for example fire alarm tests.
  • Ensure all staff complete training deemed mandatory by the practice, for example equality and diversity training.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice