The Care Quality Commission
  • Doctor
  • GP practice

Wonersh Surgery

Overall: Good read more about inspection ratings

The Surgery, The Street, Wonersh, Guildford, Surrey, GU5 0PE (01483) 898123

Provided and run by:
Wonersh Surgery

All Inspections

During an assessment under our new approach

We carried out a focused assessment on 15 October 2024. At our previous inspection in April 2024, the provider was rated Good overall and in all the key questions. However, there was a breach in Regulation 17 Good Governance. This assessment was to follow up the breach. At our previous inspection we found the provider reviewed and investigated incidents and complaints and recorded actions taken. Medicines management reflected current and relevant best practice and professional guidance. Patients' medicines were appropriately prescribed in line with the relevant legislation, current national guidance, or best available evidence. Patients' needs were assessed using a range of assessment tools to ensure their needs were reflected and understood. There were effective approaches to monitor patients' care and treatment and their outcomes. Leaders and staff were alert to experiences and outcomes that could disadvantage different groups of people using their services. There were clear governance, management, and accountability arrangements in place. However, the provider was not working to their Prescribing and medication policy and prescription stationary was not being tracked in line with NHS guidance. There was no policy for staff to follow for Patient Specific Directions (PSD). At this assessment we found that processes had been reviewed and changed or improved. We saw evidence that systems and processes were working as intended. There had been a collective approach to ensuring that improvements within the practice were sustainable. Prescription tracking was changed and included individual script numbers which were tracked throughout the practice. The changes were discussed with staff at a practice meeting. There were weekly audits to ensure the new system was working as intended. We found the provider had made the decision to no longer use PSD's and that only nurses would administer vaccinations. The Prescribing and medication policy had been updated.

During an assessment under our new approach

Date of assessment 22 April to 24 April 2024. Overall, the practice is rated as good, with all key questions rated as good. However, we found a breach of Regulation 17 Good Governance which we reported on under the Well led Key Question. The provider was not working to their Prescribing and medication policy. Prescription stationary was not being tracked in line with NHS guidance. There was no policy for staff to follow for Patient Specific Directions (PSD). The PSD’s we reviewed did not contain sufficient information for the staff member providing the vaccination and there was no record of the vaccine given added to the patient record. Following our inspection, the provider took immediate action, but we are not yet able to verify the evidence to show that actions were working as intended. We have asked the provider for an action plan in response to the concerns found at this assessment. Wonersh Surgery is an NHS GP practice located in a residential area of Guildford. The inspection included on site activity, requesting evidence from the provider and remote interviews of staff. We also completed clinical searches on the practice’s patient records system. We found the provider reviewed incidents and complaints and appropriately investigated and recorded actions taken. Medicines management reflected current and relevant best practice and professional guidance. Patient’s medicines were appropriately prescribed. Patient’s needs were assessed using a range of assessment tools to ensure their needs were reflected and understood. There were effective approaches to monitor patient’s care and treatment and their outcomes. Patients could access services when they needed to, without physical or digital barriers. Leaders and staff were alert to experiences and outcomes that could disadvantage different groups of people using their services. There were clear governance, management, and accountability arrangements in place.

12 June 2019

During a routine inspection

We carried out an announced comprehensive inspection at Wonersh Surgery on 12 June 2019 as part of our inspection programme.

We had previously carried out an announced comprehensive inspection at Wonersh Surgery in October 2014. The practice was rated as Good overall and Good in all domains. The full comprehensive report on the October 2014 inspection can be found by selecting the ‘all reports’ link for Wonersh Surgery on our website www.cqc.org.uk

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions

  • Is it Safe
  • Is it Effective
  • Is it Caring
  • Is it Responsive
  • Is it Well led

We have rated this practice as good overall and in all of the key questions. They have been rated as good overall for all population groups.

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 the practice good for providing safe, effective, caring, responsive and well-led care because:

  • 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.
  • 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 was a clear leadership structure and staff felt supported by management.
  • Staff worked well together as a team and all felt supported to carry out their roles. There was a strong team ethos and culture of working together for a common aim.

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

  • Continue to review staff immunisation records.

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

14 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We undertook a comprehensive inspection of Wonersh Surgery on the 14 October 2014.

The practice has an overall rating of good. Although some aspects of the practice required improvement.

Our key findings were as follows:

  • All practice staff work to provide the best clinical care with significant emphasis in protecting the continuity of care for patients.
  • Patient feedback about the practice and the care and treatment they received was very positive. A high percentage of patients felt they are treated with dignity and respect. This was evidenced from the national GP survey, the practice survey taken in 2014 and from patients we spoke with on the day of inspection.
  • There are a range of appointments to suit most patients’ needs. However, some patients reported difficulty in calling the practice to book appointments, accessing appointments on the same day or with their preferred GP.
  • The practice is clean and tidy, with appropriate monitoring to minimise the risk of infections.
  • Patients are well supported to manage their long term medical conditions. Patients with complex needs, living in care homes and those over 75 years have personalised care plans to facilitate a continuity of care and support from all health professionals.

We saw several areas of outstanding practice including:

  • GPs who work in the practice regularly attend child protection case meetings and have continued engagement with local authority safeguarding teams.
  • Patients with palliative care needs are supported using the Gold Standards Framework. The GPs of the practice often move beyond the requirements of the framework to support patients.

However, there were also areas of practice where the provider needs to make improvements. 

Importantly, the provider should:

  • Undertake health checks for all patients with a learning disability on their practice register.
  • Review the disposal of sharps waste in the practice to ensure this meets with national waste regulations.
  • Share successes and positive feedback from patients with staff.
  • Provide feedback to patients who have made suggestions for improvements.
  • Develop a strategic plan for the practice to include a focus in improving the operational leadership and enable the practice to remain efficient and responsive to patients’ needs.
  • Review their appointments system and telephone access to the practice in order to improve the patient experience.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice