Background to this inspection
Updated
21 July 2022
Woodend Health Centre is located in the north of the city of Coventry in the West Midlands.
There is direct access to the practice by public transport from surrounding areas. There are parking facilities on site as well as public parking on street.
The practice currently has a list size of approximately 8200 patients. The practice holds a General Medical Services (GMS) contract with NHS England. The practice is situated in an area with very high levels of deprivation. It is within the top 10% most deprived areas within the United Kingdom. Information published by Public Health England shows that deprivation within the practice population group is in the first decile (seven of 10) with one being most deprived and 10 being least deprived. The practice has a higher than national average number of children and young people. It has lower than the national average number of adults who have reached retirement age and older aged people.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.
The practice is currently managed by three GPs. The practice also has two salaried GPs. They are supported by two practice nurses and one phlebotomist. The practice also employs a practice manager, office manager and a team of reception, clerical and administrative staff.
The practice is open on Mondays to Fridays from 8.15am to 6pm. When the practice is closed patients are directed to the GP out of hours service which is accessed through the 111 service. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments. The practice is part of a wider network of GP practices, the practice is signed up to SURGE which provides GP cover at short notice for illness. This is provided by Coventry GP Alliance.
Updated
21 July 2022
We carried out an announced inspection at Woodend Health Centre on 16 May 2022. Overall, we rated the practice as Good.
Safe - Good
Effective - Good
Responsive - Inspected but not rated
Well-led – Requires Improvement
Following our previous inspection on 16 August 2016, the practice was rated Good overall and for all key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Woodend Health Centre on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focused inspection to follow up on:
This inspection included a comprehensive review of information and a site visit where we inspected safe, effective and well-led care. During our inspection we looked at one area of providing responsive care: Access to the service, this was not rated, and we did not identify any concerns with regards to access to the service.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently. Therefore, as part of this inspection we completed clinical searches on the practice’s patient records system and discussed the findings with the provider. This was with consent from the provider and in line with all data protection and information governance requirements.
The inspection also included:
- Requesting and reviewing evidence and information from the service
- A site visits
- Conducting staff interviews
- Reviewing patient records to identify issues and clarify actions taken by the provider
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 Good
We found that:
- The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse. They had established good working relationships within the local area and proactively worked towards improving the safety of patients.
- The practice assessed patient’s needs and provided care and treatment, this was delivered in line with current legislation and standards and evidence-based guidance were supported by clear pathways and tools.
- The practice was able to demonstrate that staff had the skills, knowledge and experience to carry out their roles. Regular training was completed by staff relevant to their roles and additional support was available to staff, in particular regular team meetings where staff could discuss concerns or questions.
- The practice was actively involved in schemes to help patient live healthier lives, including smoking cessation, weight management and reviewing alternatives to opioid based pain relief management. Staff we spoke with as well as records viewed demonstrating that staff had the skills, knowledge and experience to carry out their roles in order to help patients to live healthier lives.
- Oversight of systems and process were not always effective, we found the practice had failed to act on or identify out of date emergency equipment, a medication error had not been identified and regular fire drills were not taking place at the time of inspection.
- Although staff explained that Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) were in place; documents to evidence this were not available on the practice clinical system at the time of inspection. We were therefore unable to ensure they were in place for the right reasons and it was not clear how the provider was reassured good practice had been followed.
We found one breach of regulations. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
Whilst we found one breach of regulations, the provider should:
- Continue taking action to increase the uptake of cervical screening and childhood immunisations.
- The practise should continue taking actions to establish a patient participation group.
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