We carried out a review of the data available to us about Rosemead Drive Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Rosemead Drive Surgery, you can give feedback on this service.
We carried out an announced comprehensive inspection of the practice on 8 July 2015. A breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulation 12 and 19 of HSCA (Regulated Activities) Regulations 2014 .
We undertook a focussed inspection on 13 July 2016 to check that they had followed their action plan and to confirm they now met their legal requirements. This report only covers our findings in relation to those requirements. You can read the last comprehensive inspection report from the December 2015 by following the link http://www.cqc.org.uk/location/1-544619317 or selecting the ‘all reports’ link for Rosemead Drive Surgery on our website at www.cqc.co.uk
At this inspection we found that:
The significant event system had been improved with a new policy and reporting form in place and a consistent approach. Investigations identified actions which were implemented and learning shared with all staff.
The practice had introduced a process to ensure emergency equipment and medicines are checked as per the practice protocol.
There was now an effective and consistent system in place for dealing with significant events including reporting and the dissemination of learning from recorded events.
There was now a consistent system in place to ensure referrals were made in a timely manner and monitored.
Staff had received an annual appraisal.
Policies had been reviewed and updated, including the policies relating to safety alerts, safeguarding vulnerable adults and arrangements for dealing with emergencies.
The areas where the provider should make improvements are:
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Rosemead Drive Surgery on 8 July 2015. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
There was a programme of continuous clinical audit which was used to monitor quality and to make improvements.
The practice had a number of policies and procedures in place to govern activity, however some required more detail.
The areas where the provider must make improvements are:
Ensure there is a robust and consistent system in place for dealing with significant events including reporting and the dissemination of learning from recorded events.
To have in place a robust and consistent system to ensure referrals are made in a timely manner and monitored.
In addition the provider should:
Chief Inspector of General Practice
We found improvements were needed in infection control, where we found inadequate cleaning of surfaces and inadequate storage of cleaning equipment. There was also inadequate storage of clinical waste awaiting disposal in an area open to the public.
We found there were no defibrillators in either of the surgeries, though best practice would denote these were available for use. A defibrillator is a lifesaving machine that gives the heart an electric shock in some cases of cardiac arrest or irregular heart rhythm.
We found a large number of out of date medicines at one surgery, though we found medicines and vaccines were stored and dispensed appropriately at both surgeries.
We found that improvements were also needed around the recruitment policies and procedures and systems for monitoring the quality of service provision, and information around the surgery contact telephone number.