Background to this inspection
Updated
18 July 2023
Woodside Surgery (Caritas Health Partnership) is located in Halifax and operates from a main surgery (Woodside Surgery) and 2 branch sites (Shelf Health Centre and Mixenden Stones Surgery):
Woodside Surgery
Woodside Road
Boothtown
Halifax
HX3 6EL
Shelf Health Centre
Shelf Moor Road
Shelf
Halifax
HX2 8RQ
Mixenden Stones Surgery
Mixenden Road
Mixenden
Halifax
HX2 8RQ
At this inspection we visited Woodside Surgery.
The provider is registered with CQC to deliver the following regulated activities from all 3 sites:
- Diagnostic and screening procedures
- Maternity and midwifery services
- Treatment of disease, disorder or injury
- Surgical procedures
The practice is situated within the Calderdale Cares Partnership, which sits within the NHS West Yorkshire Integrated Care Board, and delivers Personal Medical Services (PMS) to a patient population of 8,797. This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices, known as a Primary Care Network (PCN). Woodside Surgery is part of North Halifax PCN.
Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the second lowest decile (2 of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is 95% white, with the remaining 5% made up of black, Asian and other mixed ethnicities.
There is a team of 2 GPs, both male, one of whom is a partner. There are 3 advanced clinical practitioners (ACPs), 1 male, who is the second partner. The other 2 ACPs are female. There is also a trainee male ACP. The clinical team is completed by 2 practice nurses and a healthcare assistant, all female.
Non-clinical support is provided by a practice operations manager, assistant practice manager and a range of data quality, reception and secretarial staff.
Woodside Surgery is open between 8am and 6.30pm Monday to Friday. The branch surgeries are open 8am to 6.30pm Monday to Thursday. Appointments with a GP, practice nurse and healthcare assistant are available on Monday and Wednesday at Shelf Health Centre and on Tuesday and Thursday morning at Mixenden Stones Surgery.
Extended access appointments are provided collectively by the PCN. The practice is open on 1 Saturday in 4 on rotation with other practices in the PCN. Evening appointments are available from 6.30pm to 8pm at a local practice.
Out of hours care is available via NHS 111 or Local Care Direct.
Updated
18 July 2023
We previously carried out an announced focused inspection of Woodside Surgery (Caritas Health Partnership) on 30 and 31 March 2022. Following that inspection, the provider was rated requires improvement overall (inadequate in safe and requires improvement in effective and well-led). We issued a warning notice for breach of Regulation 12 (Safe care and treatment) and a requirement notice for breach of Regulation 17 (Good governance).
We then carried out an announced focused inspection on 11 and 12 July 2022 to check that the provider had complied with the Regulation 12 (Safe care and treatment) warning notice. At that inspection we found the provider had improved systems and processes to demonstrate safe and effective care and treatment. We did not review the previous ratings awarded to the provider at this inspection.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Woodside Surgery our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was an announced, comprehensive, rated inspection carried out on 20 and 21 June 2023 to follow-up breaches of regulation from the previous rated inspection in May 2022.
Overall, the practice is now rated as good.
Safe - good
Effective - good
Caring - good
Responsive - good
Well-led - good
How we carried out the inspection
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:
- 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 shorter site visit.
- Reviewing staff questionnaires.
- Staff interviews.
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 found that:
- The provider had been responsive to the findings of our previous inspections and we found improvements in systems and processes to manage patient safety alerts, medicines monitoring, staff training and infection prevention and control.
- There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
- Patients received effective care and treatment that met their needs.
- There was a programme of quality improvement, including clinical audit.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Patients could access care and treatment in a timely way.
- The practice had made improvements to systems and processes to ensure good governance in accordance with the fundamental standards of care.
Whilst we found no breaches of regulations, the provider should:
- Continue with the embedding of systems and processess to ensure the proper and safe management of medicines.
- Continue to monitor and make improvements to increase the uptake of cervical screening and childhood immunisation outcomes.
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 Health Care