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Inspection Summary


Overall summary & rating

Good

Updated 5 July 2021

We carried out an announced focused review of Roseheath Surgery Ltd on 14 June 2021. Overall, the practice is rated as Good.

Following our previous inspection on 6 November 2019, the practice was rated Good overall and Requires Improvement for providing Well-led services. We also rated the population group working age people (including those recently retired and students) as Requires Improvement.

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

Why we carried out this review

We carried out this review to assess if the provider had addressed the Requirement Notice issued at the last inspection which indicated that systems and processes needed to be in place to ensure Patient Group Directives (PGDs) were appropriately authorised.

At the last inspection we rated the population group working age people (including those recently retired and students) within the Effective key question as Requires Improvement and advised the provider that they Should continue to work towards improving cervical cancer screening uptake as the screening data was not meeting the national coverage target. At this review we assessed the action the provider was taking to address this.

At the last inspection we advised the provider that they Should identify a Freedom to Speak Up Guardian and ensure that staff are familiar with who this is and their contact details. At this review we assessed the action the provider was taking to address this.

This review focussed only on evidence relating to the previous breach to regulations and other recommendations made following our last inspection. Therefore it only updated the ratings for the well led key question and working age population group. All other key question and population group ratings remain the same as following the previous inspection.

How we carried out the review

This focused review was a follow-up review of information without undertaking a site visit. 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 reviews differently. This review was carried out in a way which enabled us not to spend time on site.

This included:

  • Speaking with the practice using video conferencing
  • Requesting evidence from the provider
  • Reviewing action plans sent to us by the provider

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we reviewed the service
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

The practice continues to be rated as Good overall. The practice is now rated as Good for providing Well-led services and Good for the population group working age people (including those recently retired and students).

We found that:

  • The provider had taken action to ensure that the issues identified at the last inspection had been addressed.
  • Improvements had been made to the system for ensuring that Patient Group Directives (PGDs) were appropriately authorised.
  • There had been an improvement to the uptake of cervical screening, however uptake had been affected by the Covid 19 Pandemic. The provider had a clear action plan for continuing to improve attainment in this area.
  • The provider had identified Freedom to Speak Up Guardians and staff had received training to ensure they were aware of how to report any concerns about the operation of the service.

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

  • Continue to to work towards improving cervical cancer screening uptake.

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

Inspection areas

Safe

Good

Updated 5 July 2021

Effective

Good

Updated 5 July 2021

Caring

Good

Updated 5 July 2021

Responsive

Good

Updated 5 July 2021

Well-led

Good

Updated 5 July 2021

Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Good

Updated 5 July 2021

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good