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Inspection Summary

Overall summary & rating


Updated 10 January 2020

We carried out an announced focused inspection at Roseheath Surgery Ltd on 6 November 2019. We carried out an inspection of this service due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions:

  • Effective
  • Well Led

Because of the assurance received from our review of information we carried forward the ratings for the following key questions:

  • Safe
  • Caring
  • Responsive

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 Good overall and Good for all population groups apart from working age people (including those recently retired and students) which is rated as requires improvement.

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

  • The system for ensuring that Patient Group Directives (PGDs) were appropriately authorised was not comprehensive.

We rated working age people (including those recently retired and students) as requires improvement due to the screening data for cervical screening not meeting the national coverage target.

We rated the practice as Good for providing effective services because:

  • Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance.
  • Staff worked together and with other organisations to deliver effective care and treatment.
  • Staff told us they felt well supported and they had access to training to support them in their roles.

The area where the provider must make improvements are:

  • Systems and processes must be in place to ensure Patient Group Directives (PGDs) are appropriately authorised.

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

The areas where the provider should make improvements:

  • Identify the Freedom to Speak Up Guardian and ensure that staff are familiar with who this is and their contact details.
  • The practice should continue to work towards improving 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










Requires improvement
Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable