Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Woodlawn Medical Centre on 2 March 2016. Breaches of legal requirements were found. After the comprehensive inspection, the practice submitted an action plan, outlining what they would do to meet the legal requirements in relation to the breaches of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During the comprehensive inspection we found that the practice had failed to do all that was reasonably practicable to monitor, evaluate and improve the effectiveness of their clinical system and the service provided to patients. We also identified areas where improvements should be made, which included putting systems in place to ensure staff were up to date with mandatory training, taking steps to identify as many carers as possible, considering ways in which their branch practice could be made more accessible to patients who were unable to use stairs; and ensuring the staff were involved in discussions about the running of the service, that they knew the location of panic buttons and that they were aware how to use the electronic records system effectively.

We undertook this focussed inspection on 14 November 2016 to check that the practice had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Woodlawn Medical Centre on our website at www.cqc.org.uk.

Overall the practice was rated as requires improvement following the comprehensive inspection. They were rated as requires improvement for providing effective and caring services. Following the focussed inspection we found the practice to be good for providing an effective and caring service.

Our key findings across all the areas we inspected

were as follows:

• The practice had completed full cycle clinical audits, which demonstrated quality improvement by measuring the effectiveness and impact of improvements put in place following initial audits.
• The practice had a written vision and strategy, and we saw evidence that this had been shared and discussed with staff.

• The practice had recently appointed a new practice manager, who was in the process of re-organising the practice’s computer systems to ensure that documents were filed in an accessible way. At the time of the focussed inspection the practice manager had made significant progress with this, and staff we spoke to knew where to find key documents and information.
• The practice had put processes in place to ensure that staff were up to date with mandatory training; all staff had completed the training required.
• The practice had updated their patient record system and all staff were able to use the system effectively.
• The practice had made panic alarms available via the practice’s computer system, and all staff knew how to use these to summon assistance.
• The practice had submitted plans for the development of the Oak Lane premises in order to make it accessible for patients who were unable to use stairs. In the meantime, they had made arrangements for these patients to attend the Woodlawn Medical Centre site for minor surgery.
• We saw evidence that the practice had engaged with staff about the running of the practice.
• The practice had made changes to their systems for recording gathering and recording information about patients, and as a result had increased the number of carers identified.
• The practice had developed a website for patients with information about the service.

However there was one area of practice where the provider should make improvements:

• They should ensure that they carry-out the planned work to improve access to the Oak Lane site.

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 Woodlawn Medical Centre on 2 March 2016.  Overall the practice is rated as requires improvement.

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.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

• Staff had the skills, knowledge and experience to deliver effective care and treatment.

• Patients we spoke to said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment; however, the National Patient Survey did not reflect this and the practice scored below the local and national average in several areas.

• Information about services and how to complain was available and easy to understand.

• Patients we spoke to and those who completed CQC comment cards said they found it easy to make an appointment with a named GP and that there was continuity of care; however, this did not align with the outcome of the National Patient Survey. Urgent appointments were available the same day.

• The practice had good facilities at the Woodlawn Medical Centre site and was well equipped to treat patients and meet their needs. However, not all facilities at the Oak Lane site were accessible to patients who were unable to use the stairs.

• There was a clear clinical leadership structure; however, the interim division of the practice manager role amongst several members of staff whilst the practice tried to recruit a new practice manager meant that administrative staff did not have a clear line of accountability and there was some ambiguity about the responsibility for certain tasks. Since the inspection the practice has appointed a practice manager. 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.

There was one area where the provider must make improvements:

• They must ensure that they are taking action to evaluate and improve the effectiveness of their clinical systems and the service provided to patients.

In addition, the provider should:

• Ensure that all staff keep up to date with mandatory training.

• Take action to ensure that they are taking suitable steps to identify as many carers as possible.

• Review the results of the NHS patient survey and consider what action they need to take to address areas where they scored below average.

• Ensure that all staff are involved in discussions around the running of the service.

• Consider ways in which the Oak Lane site could be made more accessible to patients unable to use stairs.

• Ensure that all staff are aware of the location of panic buttons.

• Ensure that all staff are aware of how to use the electronic record system effectively.

• Ensure that processes are in place to ensure that new members of staff receive a comprehensive induction.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice