All inspections: Guildowns Group Practice

We carried out a review of the data available to us about Guildowns Group Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Guildowns Group Practice, you can give feedback on this service.

We carried out an announced inspection at Guildowns Group Practice from 25 – 28 July 2022 Overall, the practice is rated as Good

Safe - Good

Effective - Good

Caring – Good (carried over from last inspection)

Responsive – Good (carried over from last inspection)

Well-led - Good

Following our previous inspection on 17 May 2021, the practice was rated requires improvement overall and for safe and well led key questions but good for effective.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Guildowns Group Practice on our website at www.cqc.org.uk

Why we carried out this inspection

The practice had been previously rated as requires improvement in May 2021. This inspection was to follow up breaches of regulations 12, and 17 as identified in our previous inspection. The data and evidence we reviewed in relation to the caring and responsive key questions as part of this inspection did not suggest we needed to review the rating at this time. This inspection included aspects of the responsive key question in relation to access only.

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
Requesting evidence from the provider
A short 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 Good overall

We found that:

The practice provided care in a way that kept patients safe and protected them from avoidable harm.
Safeguarding arrangements helped support and protect the practice’s most vulnerable patients.
Appropriate recruitment checks were in place for staff working at the practice.
The premises were well maintained, and infection prevention and control measures were implemented to minimise the risks to patients.
Our clinical searches found medicines were well managed.
Patients received effective care and treatment that met their needs.
Leaders reviewed the effectiveness and appropriateness of the care the service provided. They ensured that care and treatment was delivered according to evidence-based guidelines.
There was a programme of quality improvement activity, including clinical audit.
Staff dealt with patients with kindness and respect and involved them in decisions about their care.
Patients could access care and treatment in a timely way.
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:

Continue to improve uptake of cervical screening.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

We carried out an announced inspection at Guildowns Group Practice between 14 and 20 May 2021. Overall, the practice is rated as requires improvement.

Safe – Requires improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led – Requires improvement

Following our previous inspection between 10 to 17 December 2019, the practice was rated as requires improvement overall and for providing safe, effective and well-led services. The practice was rated good for providing caring and responsive services. We carried out an unannounced focused inspection on 20 August 2020 and following this inspection we issued a Regulation 12 warning notice to the provider. The practice was not rated as a result of this inspection.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Guildowns Group Practice on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection looking at safe, effective and well led, with the previous ratings for caring and responsive carried forward.

We reviewed the breaches identified at the last inspection, including the warning notice issued in August 2020.

We issued a warning notice to the practice in August 2020 because:

Recording of significant events had not been used to identify trends or drive improvement.

• There was a lack of role specific training in place for staff in new roles.

• There was a lack of adequate supervision or monitoring of staff to ensure that referrals were completed in a timely manner.

We previously rated the practice as requires improvement for providing safe services because:

• The practice did not demonstrate that they provided care in a way that kept patients and staff safe and protected them from avoidable harm.

We previously rated the practice as requires improvement for providing effective services because:

• An effective service was not provided in relation to promoting positive outcomes for patients, for example childhood immunisations.

• There was not a comprehensive programme of quality improvement activity.

We previously rated the practice as requires improvement for providing well-led services because:

• The practice did not demonstrate that governance arrangements were operating as leaders intended.

• The practice did not have clear and effective processes for managing risk.

We also reviewed the areas where the previous inspection identified that the provider should make an improvement by:

Continuing to take action to improve uptake of cervical cancer screening.

• Reviewing and improving monitoring of staff immunisation status in line with current Public Health England guidance.

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 telephone and 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
Requesting evidence from the provider
A short site visit
A staff questionnaire emailed to all staff.

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 overall and good for all population groups.

We found that:

The practice was now compliant with the Regulation 12 warning notice issued in August 2020.
The practice had made improvements in how significant events were recorded, investigated and the learning shared appropriately.
The practice had made improvements in the areas identified at our December 2019 inspection. However, in some areas these improvements were not sufficient.
Patients received effective care and treatment that met their needs.
The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
There were some areas of medicines management that could be improved.

We found two breaches of regulations. The provider must:

Ensure that care and treatment is provided in a safe way.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The provider should:

Continue with efforts to improve the uptake of cervical cancer screening and childhood immunisations.
Consider reviewing coding of do not resuscitate cardiopulmonary resuscitation decisions within individual patient records.
Review and improve strategies to allow staff to give honest feedback.

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

We carried out an unannounced focused inspection of this service in response to concerns at Guildowns Group Practice.

We previously carried out an announced comprehensive inspection at Guildowns Group Practice on 10, 11 and 17 December 2019 as part of our inspection programme. At this inspection the practice was rated as Requires Improvement overall and in safe, effective and well led. The full comprehensive report for the December 2019 inspection can be found by selecting the ‘all reports’ link for Guildowns Group Practice on our website

We are mindful of the impact of COVID-19 pandemic on our regulatory function. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

This inspection on 20 August 2020 did not result in any new ratings.

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 found that:

in the small sample of individual care records that we reviewed suspected cancer referrals had been completed in a timely manner.
role specific induction plans and adequate supervision were not in place for staff in new job roles.
significant events were not always used to monitor trends and did not always drive improvement.

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

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection

We carried out an announced comprehensive inspection at Guildowns Group Practice on 10, 11 and 17 December 2020 as part of our inspection programme.

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 overall and good for all population groups.

We rated the practice as requires improvement for providing safe services because:

The practice did not demonstrate that they provided care in a way that kept patients and staff safe and protected them from avoidable harm.

We rated the practice as requires improvement for providing effective services because:

An effective service was not provided in relation to promoting positive outcomes for patients, for example childhood immunisations.
There was not a comprehensive programme of quality improvement activity.

We rated the practice as requires improvement for providing well-led services because:

The practice did not demonstrate that governance arrangements were operating as leaders intended.
The practice did not have clear and effective processes for managing risk.

We rated the practice as good for providing caring and responsive services because:

Staff dealt with patients with kindness and respect and involved them in decisions about their care.
Feedback received from patients regarding their care and treatment and access to the service was very positive.
The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

We found that:

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. Patients could access care and treatment in a timely way
The way the practice was led and managed promoted the delivery of person-centred care.

The areas where the provider must make improvements are:

Ensure care and treatment is provided in a safe way to patients.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

(Please see the specific details on action required at the end of this report).

The area where the provider should make improvement is:

Continue to take action to improve uptake of cervical cancer screening.
Review and improve monitoring of staff immunisation status in line with current Public Health England guidance.

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 Guildowns Group Practice on 23 February 2016. The overall rating was requires improvement. During the inspection we found breaches of legal requirements and the provider was rated as requires improvement for providing safe and well-led services. Following this inspection the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the breaches.

We carried out a focused follow up inspection on 12 January 2017, this inspection was to verify if the practice had carried out their action plan to meet the legal requirements in relation to the breaches in regulations that we had identified in our previous inspection on 23 February 2016. We found that they had completed their action plan and made significant improvements. Overall the practice was rated good. During the inspection we found a breach of legal requirements and the provider remained rated as requires improvement for providing safe services. Following this inspection the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:-

Ensuring there is an efficient system across all four sites to securely track prescriptions for high risk medicines.

This report covers our findings in relation to the concerns regarding prescriptions for high risk medicines. The full comprehensive report on the 23 February 2016 and the focused follow up report on the 12 January 2017 inspection outcomes can be found by selecting the ‘all reports’ link for Guildowns Group Practice on our website at www.cqc.org.uk.

This inspection to the main practice and the three branch surgeries was an announced focused follow up inspection to confirm the practice had carried out their action plan to meet the legal requirements in relation to the breaches in regulations that we had identified in our previous inspection on 12 January 2017. We found that they had completed their action plan and made significant improvements. Overall the practice is rated as good and the practice is now rated as good for providing safe services.

Our key findings at this inspection, 29 June 2017 were as follows:-

The practice had implemented an efficient system in all four sites to securely track prescriptions for high risk medicines.
All appropriate staff had been trained and understood the protocol for tracking prescriptions for high risk medicines.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Guildowns Group Practice on 23 February 2016. During this inspection we also inspected all three of the branch surgeries. The overall rating for the main practice and the branch surgeries was requires improvement. During the inspection we found breaches of legal requirements and the provider was rated as requires improvement under the safe and well led domain. Following this inspection the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:-

Ensuring that all complaints and safety incidents and their investigation were recorded.
Ensuring that all complaints and safety incidents were investigated thoroughly. That patients affected received reasonable support and an apology and that learning was shared appropriately to support improvement.
Ensuring recruitment arrangements included all necessary employment checks for all staff, including a Disclosure and Barring Service check or risk assessment.
Ensuring that a system of annual staff appraisals was implemented and training completed was appropriate, including safeguarding.
Ensuring that policies were up to date and specific to the practice.
Ensuring action was taken to address concerns with fire safety and legionella as identified in the fire risk and legionella risk assessments.
Ensuring that systems for storing medicines and vaccines safely were in place, in particular monitoring fridge temperatures.
Ensuring systems were in place for the calibration of clinical equipment and portable electrical equipment was safe and used appropriately.
Ensuring that the protocol for controlled medicine prescriptions was followed.
Increase engagement with patients, for example by re-establishing a patient participation group to provide patient input to the practice.

The full comprehensive report on the February 2016 inspection outcome can be found by selecting the ‘all reports’ link for Guildowns Group Practice on our website at www.cqc.org.uk.

This inspection to the main practice and the three branch surgeries was an announced focused inspection carried out on 12 and 13 January 2017. This inspection was to verify if the practice had carried out their action plan to meet the legal requirements in relation to the breaches in regulations that we had identified in our previous inspection on 23 February 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

We saw that the practice had made significant improvements since our February 2016 inspection. Overall the practice is now rated as good, however the safe domain is still an area which requires improvement..

Our key findings were as follows:

There was an open and transparent approach to safety and an effective system in place for reporting, recording and investigating significant events. Learning was shared with appropriate staff to support improvement.
Risks to patients were assessed and well managed. Including fire safety and legionella and the monitoring of fridge temperatures where vaccines were stored.
Clinical equipment was calibrated and electrical equipment had been PAT tested.
Recruitment checks were carried out in accordance with practice policy. Risks assessments where in place to determine whether a Disclosure and Barring Service (DBS) check was required.
Policies were up to date and specific to the practice.
All staff had received an annual appraisal and staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and 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.The practice had re-established a patient participation group to provide patient input to the practice.
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.

We also found the practice had made improvements:-

To patient telephone access to the practice and this was being monitored.
To pro-actively identifying carers.

However, there was one area of practice where the provider needs to make improvements.

Importantly, the provider must:

Ensure there is an efficient system across all four sites to securely track prescriptions for high risk medicines.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Guildowns Group Practice on 23 February 2016. This reports refers to the location of Wodeland Avenue. Overall the location is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment, however the practice could not provide evidence of all appropriate training for example safeguarding training.
Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were not thorough enough. Patients did not always receive an apology.
Patients were at risk of harm because systems and processes were not in place to keep them safe. For example recruitment checks, staff training, medicines management, fire and legionella risk assessments.
Information about services and how to complain was available and easy to understand. However, recording of reviews and investigations were not thorough enough. Patients did not always receive an apology.
The practice had a number of policies and procedures to govern activity, but there was no system in place to ensure that these were up to date or appropriate for the location where they were in use.
Not all staff had received an appraisal within the last 12 months, some staff had not had an appraisal for more than two years and the practice did not have a schedule in place for appraisals

The areas where the provider must make improvements are:

Ensure that all complaints and safety incidents and their investigation are recorded.
Ensure that all complaints and safety incidents are investigated thoroughly and ensure that patients affected receive reasonable support and an apology and that learning is shared appropriately to support improvement.
Ensure recruitment arrangements include all necessary employment checks for all staff, including that a Disclosure and Barring Service check or risk assessment showing a check is not required is in place for all staff.
Ensure that a system of annual staff appraisals is implemented and that training is completed as appropriate including safeguarding.
Ensure that policies are up to date and specific to the practice.
Take action to address identified concerns with fire safety and legionella as identified in the fire risk and legionella risk assessments.
Ensure that blank prescription forms are stored securely.
Ensure systems are in place to make sure clinical equipment is calibrated and portable electrical equipment is safe.
Investigate ways to increase engagement with patients, for example re-establish a patient participation group to provide patient input to the practice.

In addition the provider should:

Continue to monitor and review telephone access to the surgery.
Continue to proactively identify carers.
Review the use of patient specific directions.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Guildowns Group Practice Also known as Wodeland Avenue Surgery, 91-93 Wodleand Avenue, Guildford, Surrey

All Inspections

6 July 2023

During a monthly review of our data

27 July 2022

During an inspection looking at part of the service

17 May 2021

During a routine inspection

20 August 2020

During an inspection looking at part of the service

10 Jan to 17 Jan 2020

During a routine inspection

29 June 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)

12 January 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)

23 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)