Rosedean House Surgery

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people and were clean and well-maintained. However, risks were not always mitigated. At the time of the inspection there were not always enough staff with the right skills, qualifications and experience. Managers did not always make sure staff received an induction and training. The dispensary was managed well and people were involved in planning any changes. However, we found that there were shortfalls in relation to emergency medicines.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.
The provider had processes for staff to report incidents, near misses and safety events and these were monitored for trends, with learning from these events recorded.
There were a policy and a system to record and investigate complaints and we saw a complaint summary and learning report had been produced which identified there were no trends in complaints.
The service held team huddles and clinical patient safety meetings where information was exchanged about learning events. We evidenced examples of how this was used in practice. For example, there was learning relating to a person’s death certification and how the service made changes to the standard operating procedure as a result of this.
The service monitored significant events for trends and we saw examples of the findings such as a number of incidents relating to administration, this enabled the service to make changes that included additional staff being put into place to clear backlogs for example. Another example was through a consultation audit, the service identified that a locum clinical staff member may have missed an opportunity to diagnose a person with a health condition. We could see from the lessons learned log how this was followed up with the clinician and wider clinical team
 

The service worked with people and healthcare partners to establish and maintain safe systems of care. There were systems and processes to manage or monitor people’s safety, but they were not always effective. They did not always make sure there was continuity of care, including when people moved between different services.
The service had structured systems for triage, care navigation which included risk stratification. We observed during our site visit there were urgent appointments and routine appointments available. However, there were not always sufficient appointments available for people who required an appointment within the next few days. A member of staff highlighted this concern to us and it was raised to the provider of the service. The leaders provided rotas following the inspection which demonstrated the service was staffed to their assessed staffing levels and had used remote clinicians from their organisation to make up the shortfall.
The service had an average of 89 requests per day and recognised that on some days of the week an increase of appointments was required to ensure it could meet the needs of its patients, therefore additional clinical staff were put in place. Staff were aware of where to direct people to such as Pharmacy first, or minor injuries unit when it was appropriate to do so to reduce the demand at the practice.
There were processes for the summarising of patient records. For example, the records for newly registered patients or correspondence relating to people’s healthcare (summarising is the process of looking at patients records and extracting an accurate medical history in chronological order). However, the service had a backlog of 180 patients whose records had not been summarised. It was not clear how old the oldest record was. The service sought additional support from an external resource to be able to manage this backlog and the proposed timescale for completion was 3 months.
The service had support from an external company to manage pathology (blood test) results, this was funded by the Primary Care Network (PCN). (A PCN is a group of GP practices working together with other health and social care providers to offer a wider range of services to their local population than a single practice could provide on its own) and provides additional capacity to free up GP time. At the time of the inspection this service was being transferred to another service due to identified quality issues.
There was a back log of 1885 administrative tasks waiting to be processed. We also identified a backlog with the management of incoming documents. During the site visit we found 515 documents waiting to be processed, the oldest document was dated 14 August 2025. The service was aware of this and was mitigating risk by prioritising abnormal pathologies.
 

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.
Safeguarding policies and procedures were in place and known to staff.
The service was aware of and involved in adult risk management meetings where there was capacity to do so, which fostered a collaborative approach to safeguarding people. The Safeguarding Lead attended a community huddle where they could share information about safeguarding concerns.
The service had a process for ensuring peoples’ care records contained digital flags if there were safeguarding concerns, including adults, children and family members where appropriate.
We found that 9 staff did not have up to date Safeguarding training. The service confirmed following the inspection that there was a plan for staff to complete training during the next half day closure for protected learning time.
Leaders of the service had completed safeguarding audits. We saw there were outstanding actions relating to this audit. For example, the persons next of kin record had not been consistently updated to reflect that there were safeguarding concerns relating to a family member and incompletion of the safeguarding tab on the digital record.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated

A clinical member of staff told us how they provided safety netting information to people. This was provided in a variety of ways including written instructions or text message follow up. Staff changed their communication style to meet the needs of people. For example, when providing care and treatment for people with low literacy or cognitive needs.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.
The building was owned by the provider One Medicare Ltd and people could access the building and consultation rooms easily. The service benefitted from an inhouse maintenance team.
The service was able to provide a space away from the waiting room to protect the confidential needs of people using the service when necessary. There was also a private space where people could take their blood pressure and weight measurements. In clinical spaces privacy curtains were in place and these were observed to be in good condition.
The service had a health and safety policy and undertook regular checks of clinical rooms. A health and safety premises risk assessment had been completed by an external contractor. The service had completed a health and safety audit and there we no concerns noted.
The provider had arranged for an electrical installation condition report to be carried out by an external organisation. The assessment was deemed unsatisfactory and identified urgently required remedial action. Leaders of the service confirmed following the inspection that remedial action has been arranged and is taking place within one month following the inspection.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.
There were a range of clinical and non-clinical roles within the practice and the service benefitted from additional roles provided by the PCN such as clinical pharmacists.
We reviewed the staffing levels and found the service was not always staffed at their assessed staffing levels. For example, on one day where there was anticipated to be more patient demand we saw there were 3 clinicians on duty when 4 were required. The leaders of the service responded to this by providing rotas to us following the inspection that demonstrated the service was staffed to their assessed staffing levels and had used locums and remote clinicians from their organisation to make up the shortfall.
We reviewed 3 recruitment files and found the service had followed their policy in relation to seeking references and Disclosure and Barring Service (DBS) Checks. (Disclosure and Barring Service (DBS) is a check which enables employers to check the criminal records of current and potential employees to ascertain whether they are suitable to work). The service had also ensured appropriate references were obtained.
From the staff files reviewed, we could not evidence newly appointed staff had completed induction training. Staff we spoke with told us that they had not received a comprehensive induction. Leaders of the service developed a plan to address this, which we could not verify at the inspection as this required time to be implemented and embedded into practice.
For clinical staff, professional registrations were recorded and valid. Records of staff immunisations were available in the staff files reviewed, with the exception of one member of staff where there was an absence of a risk assessment for an immunisation the staff member had not received.
The service had processes for clinical supervision and appraisal and could monitor these were taking place through a supervision tracker. From the staff files reviewed, we couldn’t evidence staff had been receiving regular supervisions. In response to this the leaders of the service developed a plan to ensure that staff were receiving clinical supervision with their clinical supervisor. Staff confirmed they had not consistently had annual appraisals.However, the new provider was able to evidence the introduction of a tracker to demonstrate appraisals for all staff had been arranged.
Leaders of the service openly told us there were challenges with recruitment of GP’s. A member of staff said they felt their job was unsustainable due to workload pressures. Another member of staff told us the leaders of the service were supportive of continued professional development (CPD) but workload pressures could interfere with this.

The service did not always assess or manage the risk of infection.
The service held an Infection Prevention and Control (IPC) Policy. However it wasn’t clear from the policy who the IPC Lead within the service was. The service also had an overarching annual IPC plan that set out the frequency of audits and training requirements. However, we found that 7 members of staff did not have up to date IPC training.
The service had undertaken an audit to ensure that the practice was working in line with the IPC policy and procedure. The audit highlighted a number of issues to be followed up including actions for the safe storage of cleaning products, cluttered cleaning cupboards and lack of signage for spillage kits. From the services IPC report, it was not clear that action had consistently taken place in response to the findings. We noted during our site visit that the external clinical waste bin was not locked to the wall, this had been identified during the IPC audit, but not had not been actioned. This was actioned on the day of the inspection.
Staff understood their responsibilities in relation to IPC and were aware of the appropriate channels for seeking guidance and support.
Personal protective equipment (PPE) was available to staff, and the service held stocks of PPE. We saw signage on use of PPE and found handwashing facilities in clinical rooms and throughout the building. We found sharps management processes followed, with sharps bins used appropriately. There were appropriate systems for clinical specimen management. During the site visit, we evidenced the environment and equipment to be visually clean. Cleaning of the buildings was carried out by an external contractor.. We found cleaning checklists had not been completed for two months. A new checklist had been implemented but we could not evidence that this had been completed during our site visit. However, examples of these were received following the inspection. A communication book was held but not all staff we spoke with knew about this.
Cleaning equipment was stored safely but did not always contain appropriate data sheets for the products used. Such as an air freshener in the toilets.
Systems were followed to enable assessment of patients with presumed sepsis in line with NICE guidance and there were posters throughout the service highlighting information about sepsis. We evidenced the service discussed sepsis management in the clinical meeting and staff told us they received sepsis training during the services half day closure.
 

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. However, the service did not always store medicines correctly.
The service had a dispensary. We found safe systems were followed for dispensing medicines. All dispensary staff were suitably trained and had annual appraisals to make sure they were managing medicines safely.
There were suitable arrangements for ordering, storage and disposal of medicines, including those needing cold storage and for controlled drugs.
The dispensary was overseen by the lead GP. There were detailed Standard Operating Procedures (SOPs) in place covering all aspects of dispensary work. These were kept under review and signed by dispensary staff.
The surgery offered a delivery service for some patients who could not collect their medicines from the surgery and suitable records were kept and procedures followed. Some medicines were prepared into blister packs, and there were safe systems in place to manage this.
Suitable systems were in place to report any incidents or errors. Medicines alerts and recalls were received and acted upon if applicable. These were tracked to ensure all were dealt with in a timely way. Prescription stationery was stored safely and securely, and recorded on entering the practice, but the forms were not always tracked throughout the practice. However suitable systems were implemented during the inspection to ensure the location of all prescription forms was recorded, and that they were held securely.
A sample of Patient Group Directives (PGDs) were reviewed and these were evidenced to be authorised appropriately.
The service held emergency medicines including resuscitation equipment. The service had assessed which medicines were required and these were in line with national guidelines. We found there were duplicates of the assessments which meant that it was not clear which medicines were required to be held on site.
We evidenced that emergency equipment was stored appropriately and tamper proof tags were used for security. We observed one oxygen tank did not have a warning sign which was fed back to the service on the day. Emergency medicines were checked regularly and there were records held to demonstrate this.
Vaccines held within the service were ordered and stored appropriately. Where transportation was required for example, to a care home, this was managed in line with requirements to ensure medicines are kept within a specific temperature range.
We found gaps in records relating to the vaccination fridge temperature checks. We found on one occasion the temperature went outside of safe range for storage. There was no evidence of the data logger being checked or if the service had ensured vaccines were safe to use.
The service received support with people's medicine reviews through a pharmacist that was employed by the PCN. The service delivered medicine reviews to people living in care homes as part of their home rounds. We identified through our clinical searches that the service had completed 835 medication reviews in last 3 months. We reviewed a sample of 5 and found that 4 of these had been completed appropriately.
The service had undertaken quarterly audits in relation to prescribing that included general prescribing, opioids, benzodiazepines and antimicrobials. We could see the impact of these audits and noted that the service had improved its compliance rating from 63% to 79% throughout the year to date with antimicrobial prescribing.
As part of our assessment, a number of set clinical record searches were undertaken by a CQC GP Specialist Advisor.
Clinical searches found that where people were prescribed medicines that required monitoring such as Lithium and aldosterone antagonists monitoring had broadly taken place as appropriate.
People who were prescribed disease modifying anti-rheumatic drugs (DMARDS, medicines used to treat autoimmune and inflammatory conditions by slowing disease progression) such as Methotrexate, Azathioprine and Leflunomide had been monitored in line with guidance.
Our clinical searches identified that where the MHRA (Medicines and Healthcare products Regulatory Agency) had issued safety alerts for certain medicines such as SGLT2 Inhibitors (a medicine that is used to treat diabetes) people had received advise about the risks of this medicine.