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Roodlane Medical Limited - Cornwall Street, part of HCA Healthcare UK Primary Care Services Good

Inspection Summary

Overall summary & rating


Updated 11 September 2019

For this inspection the key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Roodlane Medical Limited – Cornwall street under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to rate the service.

Roodlane Medical Limited – Cornwall Street is a private GP service, providing a broad range of health services including GP consultations, health and wellbeing screening and occupational health services. The building, management team, staffing and governance structure are shared with Blossoms Healthcare LLP, which is also registered with CQC. We therefore inspected both services, producing separate reports, both of which reflect the shared services.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some general exemptions from regulation by CQC which relate to particular types of service and these are set out in Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At Roodlane Medical Limited – Cornwall Street, services are also provided to patients under arrangements made by their employer or an insurance company with whom the service user holds a policy (other than a standard health insurance policy). These types of arrangements are exempt by law from CQC regulation. Therefore, at Roodlane Medical Limited – Cornwall Street, we were only able to inspect the services which are not arranged for patients by their employers or an insurance company with whom the patient holds a policy (other than a standard health insurance policy).

The lead GP is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We received 16 completed CQC comment cards from service users. All the comments were positive about the service and staff. There were no appointments booked on the day of the inspection and therefore we were unable to speak with any patients.

Our key findings were :

  • The service reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines. 

  • The service took account of patient needs and preferences. Patients could access the service in a timely manner. 
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care, feedback we received from patients was positive.  
  • There were systems and processes in place to keep people safe such as safeguarding procedures, effective recruitment procedures and infection prevention and control, but not all risks were fully considered or managed.
  • There were systems in place to ensure good governance, but some areas lacked effective oversight.

Although we found no breaches in regulations, the provider SHOULD;

  • Review governance systems to ensure effective oversight. For example, risk management.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care

Inspection areas



Updated 11 September 2019

There were systems and processes in place to keep people safe such as safeguarding procedures, effective recruitment procedures and infection prevention and control, but not all risks were fully considered or managed.

Safety systems and processes

The service had clear systems to keep people safe and safeguarded from abuse.

  • The service had systems to safeguard children and vulnerable adults from abuse. Policies were reviewed and accessible to all staff. They outlined who to go to for further guidance and there was a named local and corporate lead for safeguarding who staff could refer to for support and advice. Staff were provided with the contact details for the local safeguarding team for both children and vulnerable adults and knew how to report concerns. A comprehensive safeguarding handbook was available to staff which included information on various types of abuse and incorporated areas such as domestic abuse and modern-day slavery. There was a notice board in the staff room with information on safeguarding adults and children, The Mental Capacity Act and Deprivation of Liberty Safeguards.
  • The provider had developed a system to discreetly sign post victims of domestic abuse to support and advice.
  • Staff whose files we viewed had received safety information from the service as part of their induction and refresher training.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
  • Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control. We saw that the environment was cleaned to a high standard. Policies and procedures were in place and accessible to staff.  An infection control audit covering all aspects of infection prevention and control such as the general environment, equipment and sharps was completed, and actions identified acted on.
  • Staff had received vaccinations relevant to their role and in line with current Public Health England (PHE) guidance.
  • A legionella risk assessment was completed (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).
  • There were risk assessments and data sheets for the control of substance hazardous to health (COSSH), for products used by clinical staff. However, not all cleaning products had been risk assessed and although data sheets were available, these had not been reviewed since July 2017.
  • The provider ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • Fire policies and procedures were in place. The practice was based in a shared building, fire drills and fire alarms testing were undertaken by management services contracted by the landlord and we saw evidence to support this. Staff had completed fire training and there were fire marshals in place. On the day of the inspection we saw that a fire risk assessment was completed in October 2017 and actions identified had been acted on. However, the risk assessment had not been reviewed. Following the inspection, the provider demonstrated that a further fire risk assessment had been completed in June 2019 and all actions had subsequently been completed.

  • A health and safety risk assessment was undertaken in October 2018, there were a number of actions which required completing.  Most of the actions had been completed and some were ongoing. However, there were blind cords patient accessible areas these had been identified in the risk assessment as low risk. The action plan stated the cords were to be secured with a time frame of within two months of the assessment. At the time of the inspection this had not been completed.
  • A recent premises risk assessment was completed in July 2019, which had recommended the need for panic alarms in consulting rooms and reception area. The time frame was within three months, at the time of the inspection the provider was in the process of obtaining quotes for installation.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety but we identified some gaps.

  • There were arrangements for planning and monitoring the number and mix of staff needed. Where needed regular agency staff were requested to ensure consistency. Clinical staff had the opportunity to rotate across the various locations.
  • There was an effective induction system for agency staff tailored to their role.
  • Staff we spoke with understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis.
  • Emergency medicines were available, but they had not completed a risk assessment in relation to the location of the medicines to ensure they would be accessible in an emergency situation.
  • When there were changes to services or staff the service assessed and monitored the impact on safety. Staff worked across both services to ensure resources were available and effectively managed.
  • There were appropriate indemnity arrangements in place. Professional indemnity arrangements were in place for GPs.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. There was a central electronic patient record system, which had safeguards to ensure that patient records were held securely, and the level of access limited to appropriate staff. Information needed to plan and deliver care and treatment was available in a timely and accessible way. This included investigation and test results.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. This included the patients NHS GP with consent from the patients.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.

Safe and appropriate use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including equipment minimised risks. The service did not fully consider the risks of their arrangements for managing emergency medicines. The service kept prescription stationery securely and monitored its use.
  • The service carried out regular medicines audit to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • Staff prescribed and administered medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines.
  • There were effective protocols for verifying the identity of patients.

Track record on safety and incidents

The service had a good safety record, but we identified some gaps.

  • There was a suite of risk assessments in relation to safety issues, however, these were not always fully embedded. For example, COSHH risk assessments were not all completed and although blind cords were assessed, the provider was unable to demonstrate that any action had been taken.
  • The service monitored and reviewed safety activity, this enabled the service to understand most but not all risks but provided a clear and current picture that led to safety improvements.

Lessons learned and improvements made

The service had systems in place to enable them to learn and make improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff we spoke with understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and took action, we saw evidence to confirm this.
  • Staff we spoke with were aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team including sessional and agency staff.



Updated 11 September 2019

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed and delivered care and treatment in line with current legislation and national guidance.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service).

  • The provider assessed needs and delivered care in line with relevant and current evidence-based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients. For example, the provider had a central clinical system for managing patient records, this included a search and alert function.
  • Staff assessed and managed patients’ pain where appropriate.
  • The provider had developed an electronic application to ensure that patients could log into a patient portal online using their smart phone, through which they could book appointments, securely access their medical records and complete health and wellbeing questionnaires ahead of their appointments. This ensured information was up to date and enabled the clinician to review relevant information prior to the appointment.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  •  We saw evidence of clinical audits completed in areas such as back pain, and record keeping. Senior managers recognised the need to develop a comprehensive programme of clinical audits.

Effective staffing

The system in place to ensure that staff had the skills, knowledge and experience to carry out their roles was not always operating as intended.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • Relevant professionals were registered with the General Medical Council (GMC) and were up to date with revalidation
  • The provider understood the learning needs of staff and offered protected time and training to meet them. Staff were encouraged and given opportunities to develop.
  • Up to date records of skills, qualifications and training were maintained in line with requirements.
  • Staff whose role included cervical screening and reviews of patients with long- term conditions had received specific training and could not fully demonstrate that they were up to date in one area. Following the inspection, the provider addressed this.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. For example, appropriate secondary care services.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. Patients had the opportunity to complete a health and wellbeing screening questionnaire online where they could log into a patient portal using their smart phone or in person. All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.
  • Where relevant patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP. Clinical staff were aware of their responsibilities to share information under specific circumstances (where the patient or other people are at risk). For example, medicines liable to abuse or misuse, and those for the treatment of long-term conditions such as asthma. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP or given to patients to take to their GP in line with GMC guidance.
  • Patient information was shared appropriately with consent (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following- up on people who had been referred to other services.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice, so they could self-care. Risk factors were identified and highlighted to patients.
  • The service provided a range of screening in areas such as cancer, heart and general lifestyle health. Patients were encouraged to undergo cervical tests, liver function and advanced cardiac screening tests based on their individual needs.
  • Healthy lifestyle modification advice was provided opportunistically and on an ongoing basis in areas such as diet, exercise and weight management.
  • Where patients need could not be met by the service, staff redirected them to the appropriate service for their needs. This included services local to them.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance.

  • Staff we spoke with understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately.
  • For patients whose costs were not being paid by their employer, treatment costs were clearly laid out and explained in detail before treatment commenced.



Updated 11 September 2019

Staff dealt with patients with kindness and respect and involved them in decisions about their care.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treated people.
  • Staff we spoke with understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Interpretation services were available for patients who did not have English as a first language. There were notices in the reception areas informing patients this service was available and staff we spoke with understood how to access the service. Information leaflets were available in easy read formats upon request, to help patients be involved in decisions about their care.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • The provider told us that patients with learning disabilities or complex social needs, or those who needed family, carers or social workers to be involved in their care were not within their patient population.
  • The provider enabled staff to communicate with people in a way that they could understand, for example, communication aids and easy read materials were available upon request.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.



Updated 11 September 2019

The service organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider understood the needs of their patients and adjusted services in response to those needs. Appointments were available on the same day and a seamless referral processes was in place to specialist services and consultants. Patients could be seen at a location near to where they lived or worked.
  • The facilities and premises were appropriate for the services delivered.
  • Reasonable adjustments had been made so that people with any additional needs could access and use services on an equal basis to others. For example, there was a hearing loop system for patients with a hearing impairment. The service could be accessed via a lift and there were accessible toilet facilities were available within the premises. There was a fire evacuation chair and staff were trained in its use. 
  • The provider had identified an increase in patients reporting domestic abuse. In response to this an organisation wide domestic abuse working group had been established. Staff were provided with information and training. A system had been developed to enable patients to discreetly access information and support from domestic abuse support helplines.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • There was centralised booking system for appointments. All patient calls were handled by a call centre. Telephone call response times were monitored to ensure calls were answered in a timely manner.
  • Patients had timely access to initial assessment, test results, diagnosis and treatment. Including through the patient portal on the application for smart phones.
  • Waiting times, delays and cancellations were minimal and managed appropriately. Data provided by the provider showed 92% of patients attending the service in Birmingham were seen within five minutes of their appointment time, and 69% were seen before their scheduled appointment time.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients whose feedback we reviewed reported that the appointment system was easy to use.
  • Referrals and transfers to other services were undertaken in a timely way.

Listening and learning from concerns and complaints

There was a system in place to enable the service to take complaints and concerns seriously and respond to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. The provider had received no formal complaints in the last 12-months.
  • The service had a system in place to inform patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. The system did not fully enable the provider to learn lessons from individual concerns, complaints and from analysis of trends. For example, the service did not have a system for documenting verbal complaints. Following the inspection, the service provided us with a policy for formally recording verbal complaints. Systems were in place to act as a result of identified issues to improve the quality of care.



Updated 11 September 2019

There were systems in place to ensure good governance, but some areas lacked effective oversight.

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. Members of the senior management team including the chief executive and executive director of Primary Care used regular newsletter to engage with staff, keep staff up to date with changes and celebrate achievements.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service. The provider demonstrated that they offered opportunities for career planning and post graduate business degrees for senior clinical staff.

Vision and strategy

The service had clear vision and strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a strategy and supporting business plans to achieve priorities. The service had a written mission statement which was on display and highlighted a commitment to care and improvement.
  • The service developed its vision, values and strategy jointly with staff and external partners.
  • Staff we spoke with were aware of and understood the vision, values and strategy and their role in achieving them.
  • The service monitored progress against delivery of the strategy.
  • The vision and strategy at corporate level included investing in under resourced areas to create employment within the local community.


The service had a culture of high-quality sustainable care.

  • Staff we spoke with felt respected, supported and valued.
  • The service focused on the needs of patients.
  • Leaders and managers had a system that allowed them to act upon behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were values demonstrated by staff and leadership at the practice. The system in place to respond to incidents and complaints reflected this.
  • The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour, formal training for this was carried out as part of the corporate induction.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals. Staff were supported to meet the requirements of professional revalidation where necessary. All staff were considered valued members of the team. Clinical staff were given protected time for professional development and evaluation of their clinical work.
  • The provider had a dedicated learning academy which ensured delivery of the training programme for staff.
  • There was a strong emphasis on the safety and well-being of all staff. Staff had access to the Employees Assistance Programme to help promote wellbeing and provide staff with the opportunity to obtain support if needed. We saw that there was an online forum, that staff could access through the electronic medical records system, to access advice and support in real time. This was to promote wellbeing and reduce isolation as well as ensure that other clinical staff were available for advice.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff we spoke with felt they were treated equally.
  • There appeared to be positive relationships between staff and teams.

Governance arrangements

There were responsibilities, roles and systems of accountability to support good governance and management, however, some were not location specific.

  • Structures, processes and systems to support good governance and management were in place. The provider had a corporate governance committee with oversight and accountability of the governance across all service locations. The chief nursing officer was the chair of the governance committee and regular meetings were held. Managers from each service location either attended in person or by conference call. Incidents and complaints were discussed in the governance meetings and then shared with staff at team meetings. However, we identified areas which lacked effective governance oversight for example health and safety and an example of one gap in staff training. 
  • Staff were clear on their roles and accountabilities.
  • Leaders had established proper policies, procedures and activities to ensure safety but had not always assured themselves that they were operating as intended. Some policies we viewed were generic and had not been personalised to the location.

Managing risks, issues and performance

There were clear processes for managing risks, issues and performance but these were not always fully effective.

  • There was a process to identify, understand, monitor and address current and future risks including risks to patient safety. However, we identified gaps in the consideration and management of risk. For example, blind cords had been assessed and although work had been planned no action had yet been taken. COSHH risk assessments were not always comprehensive.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of safety alerts and incidents.
  • Clinical audits were completed although this was an area for further development.

  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and performance information was discussed in regular governance meetings to monitor and improve the service.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • Patients could provide feedback by completing an online survey which was issued after each appointment. The results from all service locations were collated and analysed every three months. We saw that the feedback was very positive about the service and staff. Feedback was shared with staff through newsletters and staff meetings. Individual comments relating to the Birmingham location could be identified and was positive and there was specific data for each service location.
  • We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. For example, the provider told us they conducted staff surveys.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • The service made use of internal and external reviews of incidents. Learning was shared and used to make improvements.
  • There were systems to support improvement and innovation work for example the use of technology such as a smart phone application for patients to review their records and book appointments.
  • The provider had completed the accreditations for the International Organization for Standardization (ISO) and Safe, Effective, Quality Occupational Health Service (SEQOHS).