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:
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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:
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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.
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Alerts were included as a standard agenda item at all meetings.Discussions were recorded and actions noted.
Other key findings were as follows:
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Significant events were recorded and discussed for the purpose of learning.However, they were not always identified and thoroughly investigated.
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The practice had clearly defined and embedded systems to minimise risks to patient safety.
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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:
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Significant events should be analysed thoroughly.
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There should be a record of checks made on doctors’ bags.
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GP safeguarding training records should be easily accessible.
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Locum GPs personnel files should be easily accessible.
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The provider should implement systems to improve the patient satisfaction rates with service they receive.
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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