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Inspection carried out on 06/11/2019

During an inspection looking at part of the service

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 carried out on 3 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at this practice on 12 February 2015.

A breach of legal requirements was found. The practice was required to make improvements in the domain of ‘Effective’.

After the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

Regulation 23 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. Supporting staff; which corresponds with:

Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staffing.

We undertook this focused review to check that the provider had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Roseheath Surgery Ltd on our website at

Our key findings were as follows:

  • The practice had addressed the issues identified during the previous inspection.

  • Staff had received the appropriate training required for their role. There was a training matrix in place to monitor when refresher training was due.
  • A comprehensive staff appraisal system was in place. Staff learning needs were identified and development needs were met, for example, in relation to the health care assistants as their roles developed.
  • Work to correctly identify those patients vulnerable to unplanned hospital admission had been completed and care plans for these people were in place.
  • The practice website gave information to meet the needs of each population group. Work to engage effectively with younger patients was on-going.

We identified areas where the practice could make improvements, at our inspection in February 2015. We found that the practice had also responded to this. Our findings showed:

  • The practice had reviewed performance in customer service, year on year by holding annual reviews of complaints and compliments to help identify any emerging trends.

  • Risk assessments on water testing for Legionella were kept and available for review along with a record of water temperature testing.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 12 February 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

This is the report of findings from our inspection of Roseheath Surgery Ltd. (“the practice”). Our inspection was a planned comprehensive inspection which took place on 12 February 2015.

Roseheath Surgery Ltd is rated overall as good. We found care and treatment delivered to patients was safe, responsive and caring. Leadership was present and staff felt supported in delivery of their duties. We found some improvements were required in the domain of effective.

Our key findings were as follows:

  • The practice provided safe care and treatment to patients. Multiple data sources were used by the practice to drive improvements. Staff understood how incidents should be reported, although there were gaps in staff knowledge of what should be reported, for example, in response to any patient complaint about a clinician.
  • Some staff had not received annual performance appraisal and key training updates
  • Patients commented positively about the care and treatment they received, and on how they were treated with dignity and respect.
  • Patients we spoke with told us the practice was responsive to their needs; appointment availability was good and patients said that they did not experience lengthy delays when trying to book appointments for example, for the following day.
  • All staff we spoke with told us they received good support from the office manager. The lead nurse told us they had a good working relationship with the lead GP for the practice, and that GPs and nursing staff worked well together.

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

Importantly, the provider must:

  • Ensure that staff performance review and appraisals are in place and delivered annually and that training meets the needs of all staff.

In addition the provider should:

  • Keep sufficient records at the practice to enable review of performance year on year, for example, in relation to complaints. Also, keep copies of records to show legionella checks have been completed.
  • Complete audit cycles to enable conclusions to be drawn and improve patient outcomes.
  • Check that the correct data search is applied to identify those patients vulnerable to unplanned hospital admission, and that their care plans are reviewed by those ultimately responsible for their care.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice