Woodend Health Centre

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