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Inspection carried out on 14 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Roseworth Surgery on 14 April 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
  • Risks to patients were assessed and well managed.
  • The practice carried out clinical audit activity and were able to demonstrate improvements to patient care as a result of this.
  • Feedback from patients about their care was positive. Patients reported that they were treated with compassion, dignity and respect.
  • The practice had obtained good National GP Patient Survey results in relation to appointment availability and experience and ease of making an appointment. 93% of patients described their experience of making an appointment as good compared to the CCG average of 75% and the national average of 73%.
  • Urgent appointments were usually available on the day they were requested. Pre- bookable appointments were available within acceptable timescales.
  • The practice had a number of policies and procedures to govern activity, which were reviewed and updated regularly.
  • The practice had proactively sought feedback from patients and had an active patient participation group. The practice implemented suggestions for improvement and made changes in response to feedback. For example, comments received via the practice suggestion box had led to a review of the practice search and recall system to ensure patients with comorbidities were invited to one annual review
  • The practice used the Quality and Outcomes Framework (QOF) as one method of monitoring effectiveness and had achieved 98.6% of the point’s available (local clinical commissioning group average 96.7% and national average 94.7%)
  • Information about services and how to complain was available and easy to understand.
  • The practice had a clear vision in which quality and safety was prioritised. The strategy to deliver this vision was regularly discussed and reviewed with staff and stakeholders.
  • Practice staff were aware of, and complied with Duty of Candour requirements.

We saw an area of outstanding practice:

  • Patients who lived outside of the practice catchment area but who worked in the area were able to register with the practice.

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

Importantly, the provider should:

  • Ensure that a risk assessment is in place detailing why it has not been felt necessary for all staff to undertake a Disclosure and Barring Service (DBS) check.
  • Consider replacing the carpeting in one of the nurse’s consultation rooms with easy to clean flooring.
  • Consider ways of more proactively identifying and supporting carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

CQC Insight

These reports bring together existing national data from a range of indicators that allow us to identify and monitor changes in the quality of care outside of our inspections. The data within the reports do not constitute a judgement on performance, but inform our inspection teams. Our judgements on quality and safety continue to come only after inspection and we will not make judgements on data alone. The evidence tables published alongside our inspection reports from April 2018 onwards replace the information contained in these files.