20 and 21 June 2023
During a routine inspection
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