Woosehill Medical Centre

We carried out an announced inspection at Woosehill Medical Centre on 28 April 2022. Overall, the practice is rated as Requires improvement.

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led – Requires improvement

Why we carried out this inspection

We carried out an announced comprehensive inspection on 28 April 2022 as part of our inspection programme because the provider of the regulated services had changed. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Woosehill Medical Centre on our website at www.cqc.org.uk

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

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:

• Conducting staff interviews using video conferencing facilities
• 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 short site visit

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 have rated this practice as Requires Improvement overall. The key questions of effective, caring and responsive were rated Good. However, we rated the practice as Requires Improvement for providing safe and well-led services because:

• The practice had a recall system for patients needing ongoing monitoring of conditions. However, it was not always operated effectively.
• There was a system to monitor safety alerts from the Medicines Healthcare and products Regulatory Agency. However, not all staff had up to date knowledge.
• There was a system to monitor the competence of non-medical prescribers. However, it was not always operated effectively.
• Staff were up to date with training required by the practice except for two members of administration staff who had not completed infection prevention and control training in accordance with the practice policy at the time of inspection.
• The practice had systems and processes to support their governance and management processes, however they were not always operated effectively.
• Systems and processes to manage risks existed. However, we were not assured they were always operated effectively because we found risks to patients had not been identified and mitigated appropriately.

We also found that:

• Staff demonstrated they had good knowledge of safeguarding and chaperoning policies and processes.
• The premises were clean, tidy and well managed.
• Staff learnt from significant incidents and when things went wrong, the practice apologised.
• Patients received effective care and treatment that met their needs.
• The practice had a complaints policy and was open, honest and transparent when responding to complaints.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• There was a programme of quality improvement initiatives and a culture of continuous learning.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• There was a culture of high quality and person-centred care for patients.
• The practice planned services to meet the needs of their patient group and had a strategy to ensure effective care for all patients remained sustainable.
• The practice recognised the importance of their Patient Participation Group and acted on suggestions.
• Leaders were approachable and proactive when staff needed advice, guidance or support.
• Staff were supported to develop and take on additional responsibilities.

We found one breach of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.

(Please see the specific details on action required at the end of this report).

In addition, the provider should:

• Review their policy and processes to notify staff that a patient is a parent of a child on the safeguarding register.
• Complete the action to replace the flooring in the premises to ensure full compliance with infection prevention and control requirements.
• Source a Freedom to Speak Up Guardian for staff to access to raise concerns freely should they need to.

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