Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the practice of Woodbank Surgery on 9 June 2017. Overall the practice is rated as good.

The practice had been previously inspected on 19 July 2016. Following that inspection the practice was rated as overall requires improvement with the following domain ratings:

Safe: Requires Improvement

Effective: Requires Improvement

Caring: Requires Improvement

Responsive: Good

Well led: Requires Improvement

At that time:

• The provider did not demonstrate good governance and had not implemented effective governance arrangements to improve communication among the staff team, keep staff informed about identified risks and the ongoing monitoring and reviewing of the safety of the service including information about significant events, medical alerts, for the purpose of learning and improving outcomes for patients.

The practice provided us with an action plan detailing how they were going to make the required improvements.

The full comprehensive report on the 19 July 2016 inspection can be found by selecting the ‘all reports’ link for Woodbank Surgery on our website at www.cqc.org.uk.

This full comprehensive inspection on 9 June 2017 was to confirm if the required actions had been completed and award a new rating if appropriate. Following this re-inspection, our key findings across all the areas we inspected were as follows:

Since the last inspection the practice had made the following improvements:

• The practice kept minutes of all meetings.These minutes were shared with the whole staff team including staff that were unable to attend the meeting.

• Alerts were included as a standard agenda item at all meetings.Discussions were recorded and actions noted.

• Significant events were discussed at staff meetings.

• The medical alerts / critical alerts policy had been reviewed and implemented.

• A nominated person was appointed to keep an electronic record / log book of all staff members being in receipt of any alerts.

• An audit of searches for alerts that require any action would be completed.

Other key findings were as follows:

• Significant events were recorded and discussed for the purpose of learning.However, they were not always identified and thoroughly investigated.

• The practice had clearly defined and embedded systems to minimise risks to patient safety.

• Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.

• Clinical audits had been carried out and we saw evidence that audits were driving improvements to patient outcomes.
• The national GP patient survey results were published in July 2016. The results showed the practice was performing in line with and below local and national averages.
• Information about how to complain was available. Complaints received were not always logged and managed through the practice’s complaint procedure.
• The practice was equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff told us they felt supported by management.
• The practice proactively sought feedback from staff and patients, which it acted on.

The areas where the provider should make improvement are:

• Significant events should be analysed thoroughly.

• There should be a record of checks made on doctors’ bags.

• GP safeguarding training records should be easily accessible.

• Locum GPs personnel files should be easily accessible.

• The provider should implement systems to improve the patient satisfaction rates with service they receive.

• Detailed records should be kept of discussions held about patients who require end of life care.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Woodbank Surgery on 19 July 2016. Overall the practice is rated as requires improvement.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were not always carried out and there was sometimes no documented evidence of learning and communication with staff.

• Although risks to patients who used services were assessed, the systems and processes were not always implemented to ensure patients were kept safe. For example, areas of concern arose in relation to the management of READ coding and scanning patient information onto the IT system.
• The fire alarm had been regularly tested and up to date fire risk assessments had been carried out. Small electrical equipment was checked to ensure its safe use.
• The practice encouraged its patients to attend national screening programmes for bowel and breast cancer screening. Performance for breast screening for females aged between 50 and 70 was better than the national average.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

• Information about how to complain was available and easy to understand. Not all complaints had been logged and there was no detailed evidence of the learning outcomes.

• Staff gave mixed reviews about the level of support they received from senior staff.

• Communication systems were in place although they did not always work well. For example, we were told that locum GPs did not always receive effective supervision for their role.

The areas where the provider must make improvements are:

• Implement more effective governance  arrangements to improve communication among the staff team, keep staff informed about identified risks and the ongoing monitoring and reviewing of the safety of the service including information about significant events, medical alerts, for the purpose of learning and improving outcomes for patients.

The areas where the provider should make improvement are:

• Establish a system to check and monitor administrative systems around scanning patient information.
• The practice should complete the task of obtaining DBS checks for those staff acting as chaperones.
• A register of carers should be kept. 
• Medicines should  be stored securely and a record of the emergency medicines stored should be kept for the purpose of auditing.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We reviewed the information available to us about Woodbank Surgery on 14 June 2019. 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.