Woodland Drive Medical Centre

Updated 17 November 2023

Woodland Drive Medical Centre is in Barnsley at:

Woodland Drive,

Barnsley,

South Yorkshire,

S70 6QW.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning treatment of disease, disorder or injury and surgical procedures.

The practice offers services from the main practice location only and operates from 8am to 6pm every weekday.

The practice is situated within the south Yorkshire Integrated Care System (ICS) and delivers Personal Medical Services (PMS) to a patient population of 5,250. This is part of a contract held with NHS England.

The practice is part of the Penistone Primary Care Network (PCN), which consists of 6 member practices with a total patient population of approximately 56,000.

The practice deprivation ranking is 4 out of 10. The lower the number or ranking, the more deprived the practice population is relative to others.

According to the latest data available, the ethnic make-up of the practice area is 96% White, 1.7% Asian, 1.1% Black, 0.8% Mixed and 0.4% Other.

The provider is the lead GP. There is a salaried GP and regular team of locums who provide nurse-led clinics. The GPs are supported at the practice by a team of reception and administration staff. The practice manager and assistant practice manager provide managerial oversight.

Updated 17 November 2023

We carried out an announced inspection at Woodland Drive Medical Centre on 26, 27 and 28 September 2023. Overall, the practice is rated as Good.

Ratings for the key questions are:

Safe – Requires Improvement

Effective – Good

Caring – not inspected, good rating carried over from previous inspection.

Responsive – Good

Well-led – Good

We inspected the practice on 26 May 2021, to follow up on concerns we received about the service. This was undertaken using a pilot methodology for a remote GP focused inspection and therefore we could not rate or amend ratings for the practice at this time. However, we did identify a breach of regulations relating to governance. The practice had previously been rated as good following an inspection in February 2016.

We inspected the practice in May 2022 to follow up the breach identified at the 2021 inspection, and we rated the practice requires improvement overall and for providing safe, effective, and well-led services. We found that some improvements had been made. Patient care and treatment had mostly been well managed and access to appointments had been maintained and improved. However, we found breaches of regulations in that recruitment procedures were not established and operated effectively and systems and processes to ensure good governance in accordance with the fundamental standards of care were not effectively managed.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Woodland Medical 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:

• A breach of regulations and recommendations identified in the previous inspection.
• We reviewed the key questions safe, effective, responsive and well-led.

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
• 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.
• A 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

We found that:

• Improvements had been made since our last inspection.
• The practice had improved systems, practices and processes to keep people safe and safeguarded from abuse. However, Disclosure and Barring service checks had not always been obtained prior to employment of staff and a risk assessment had not been completed to support this decision.
• The practice had improved systems for the appropriate and safe use of medicines.
• Patients received effective care and treatment that met their needs. The practice had improved the care and treatment of patients with long term conditions.
• Training had been improved and brought up to date and the provider could demonstrate that staff had the skills, knowledge and experience to carry out their roles.
• The provider had continued to improve access and patients could access care and treatment in a timely way.
• The overall governance arrangements had improved and were effective, and the practice had improved processes for managing risks.
• There was evidence of systems and processes for learning and continuous improvement.

We found 1 breach of regulation. The provider must:

• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed and ensure specified information is available regarding each person employed.

The provider should:

• Complete regular fire drills.
• Implement emergency equipment checks at the recommended intervals.
• Update the cold chain policy and procedure to include data loggers and the action to take in the event of a cold chain breach. Monitor and record the minimum and maximum temperature of the vaccine refrigerator.
• Review and improve the detection rate percentage of new cancer cases treated and which resulted from a two week wait.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care