We carried out an announced comprehensive inspection at Woodlands Medical Practice on 26 February 2019 as part of our inspection programme.

The practice was previously inspected in September 2016 and rated as good overall.

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 rated this practice as good overall but requires improvement for providing responsive services. We rated the practice requires improvement for responsive because:

• Patient satisfaction with telephone access and making and accessing appointments was consistently lower than average compared to other GP practices. Although the practice had introduced improvements, the practice had not yet assessed the effectiveness of actions taken and could not demonstrate changes made had been fully embedded and were sustainable.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

• Follow through with plans to meet with local community pharmacists with a view to agreeing a protocol to monitor uncollected prescriptions.
• Continue to improve the uptake for childhood immunisations and cervical screening to achieve the national targets.
• Follow through with plans to assess the impact of changes made to services and continue to consider where further improvements could be made with a view to improving patient satisfaction levels.

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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Woodlands Medical Practice on 7 September 2016. Overall the practice is rated as good.

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 been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. 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.

The areas where the provider should make improvement are:

• Consider preparing a business plan to assist in forming and reviewing its future plans for development of the practice.
• Monitor quality and outcomes framework (QOF) exception reporting and work to improve patient outcomes in QOF.

Professor Steve Field CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

This visit was a follow up to our inspection of the practice on 03 December 2013.

We had found that there was no effective system in place to assess the risk of health care associated infections and to prevent, detect and control their spread. There was no designated staff member who had been appointed as Infection Prevention and Control (IPC) lead for the practice and no formal risk assessment in relation to infection prevention and control.

Following our inspection in December, the provider sent us a plan of the actions intended to meet the requirements of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We carried out this visit on 19 June 2014 to check that the actions in that plan had been implemented.

We found that the provider had taken appropriate action and was now compliant with the regulations.

We spoke with four patients at the practice on the day of our visit. They told us they were happy with the care and treatment provided. For example, one patient told us “I really like it here, my doctor is very good.” Another patient said, “it is a good practice.” Everyone told us their privacy and dignity had been respected by staff. Patients said they received clear explanations of care and treatment from doctors and nurses. For example, one patient said "the GP never rushes me and takes their time to explain things in a way I understand." Patients said it was relatively easy to make an appointment at a convenient time.

Staff demonstrated the knowledge and skills needed to protect children and adults from possible abuse.

Patients we spoke with considered the practice was always clean and we saw there were systems in place to reduce the risk of infection. However, although staff told us they were aware of infection control risks there had been no formal risk assessment of the practice in relation to infection prevention and control. As a result the provider could not be assured that people were protected against the risk of exposure to a health care associated infection.

Patients were not always protected against the risks associated with medicines because the provider did not always have appropriate arrangements in place to manage medicines. We saw that the temperature of the fridges used to store vaccines requiring cold storage, was not being measured on a daily basis and there were not clear protocols in place for managing medicines.