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Review carried out on 9 September 2021

During a monthly review of our data

We carried out a review of the data available to us about Rosedale Surgery on 9 September 2021. 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 Rosedale Surgery, you can give feedback on this service.

Inspection carried out on 6 November 2019

During an inspection looking at part of the service

We previously carried out an announced comprehensive inspection at Rosedale Surgery on 16 October 2018. The practice was rated as good overall and good for providing safe, caring, responsive and well led services. It was rated requires improvement for providing effective services and for providing effective services for the population groups; people with long term conditions and people experiencing poor mental health (including people with dementia). As a result of the findings on the day of the inspection, the practice was issued with a requirement notice for Regulation 9 (person centered care).

We carried out an announced focused inspection at Rosedale Surgery on 6 November 2019. This inspection was to follow up on the breaches of regulation identified at the previous inspection.

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.

The practice is rated as good overall, and good for providing effective services, good for the population groups of people with long term conditions and people experiencing poor mental health (including people with dementia)

We found that:

  • Improvements had been made to ensure patients received appropriate follow up in a timely manner and the number of patients with mental health needs who were excepted from the Quality Outcomes Framework (QOF) had been reduced.
  • Additional staffing resources were available, and improvements had been made to the recall systems and process to ensure patients were encouraged to attend their appointments.

In additional we followed up on areas where the practice should make improvements which were identified in our previous inspection.

We found that;

  • The practice had implemented systems and process for identifying risks in relation to fire and premises safety.
  • There was a system to ensure prescription stationery was monitored safely and effectively. Improve the tracking in and out of prescription paper.
  • The practice had ensured that patients with a learning disability had received appropriate monitoring and review.

Area where the provider should make improvements;

Continue to review and monitor the systems and processes including exception reporting in place to ensure patients receive appropriate follow up in a timely manner.

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 16/10/2018

During a routine inspection

This practice is rated as Good overall. (Previous rating January 2015 - Good)

The key questions at this inspection are rated as:

Are services safe? – Good.

Are services effective? – Requires improvement.

Are services caring? – Good.

Are services responsive? – Good.

Are services well-led? – Good.

We carried out an announced comprehensive inspection at Rosedale Surgery on 16 October 2018. This was part of our planned inspection programme.

At this inspection we found:

  • The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. Risks were assessed and acted upon, however there was no formalised process for identifying the risks in relation to fire and premises safety.
  • Effective processes were in place for the management of medicines. All prescription stationary was kept secure, although there was not an effective tracking system for prescription paper.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured care and treatment was delivered according to evidence-based guidelines. The practice’s performance on quality indicators for mental health and long-term conditions was in line with and above the Clinical Commissioning Group (CCG) and England averages. However, the exception reporting for some of the Quality and Outcomes Framework (QOF) indicators for diabetes, asthma and Chronic Obstructive Pulmonary Disease (COPD), were higher than the CCG and England averages. They were significantly higher for some of the mental health and dementia indicators and some of these had increased significantly from the year 2016/2017 to 2017/2018. Although the practice excepted patients in line with QOF requirements, a significant number of patients were not receiving the interventions and there was no evidence of additional outreach to increase this.
  • Staff worked together and with other health and social care professionals. Multi-professional meetings were held where patients with, for example, palliative care, or complex needs were discussed and reviewed. The practice encouraged other professionals to engage with the practice and invited them to six monthly informal meetings.
  • The practice had 77 patients on the learning disability register and 45 had received a health check. They were aware of this and although they had not completed many learning disability health checks since April 2018, appointments had been scheduled to catch up with these.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • The practice gave patients timely support and information. There were some examples where the flexibility of the same day team clinicians had resulted in patients being given more time.
  • Patients found the appointment system easy to use and reported they could access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the practice. Regular training tutorials were held for practice staff. All staff received an appraisal. Staff reported feeling well supported.
  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.

The areas where the provider

must

make improvements as they are in breach of regulations are:

  • Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences.

The areas where the provider should make improvements are:

  • Formalise the process for identifying risks in relation to fire and premises safety.
  • Improve the tracking in and out of prescription paper.
  • Continue to improve the uptake of health checks for patients with a learning disability.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection carried out on 8 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Rosedale Surgery has a practice population of approximately 11700 patients. We carried out a comprehensive inspection at Rosedale Surgery on 8 October 2014.

We have rated each section of our findings for each key area. We found that the practice provided a safe, effective, caring, responsive and well led service for the population it served. The overall rating was good and this was because the practice staff were extremely well organised which, led to a very efficient service. Each senior member had dedicated roles. Improvements had been identified and made that had a positive impact on patient care. For example, longer appointment times were provided for patients with long term conditions such as diabetes and vulnerable patients who had learning disabilities.   

Our key findings were as follows:

  • We found evidence that the practice staff worked together to make ongoing improvements for the benefit of patients.
  • Each day there was an assigned duty doctor to respond to any unexpected peaks in patient requests to be seen. The feedback we received from patients informed us they could get appointments when they needed to.
  • The practice was able to demonstrate a good track record for safety. Effective systems were in place for reporting safety incidents. Untoward incidents were investigated and where possible improvements made to prevent similar occurrences.
  • We found that patients were treated with respect and their privacy was maintained. Patients informed us they were satisfied with the care they received. One comment card we received stated; ‘Excellent service at all times.’

We saw an areas of outstanding practice:

  • The practice was exceptionally well organised and this resulted in an efficient service that was well led for the benefit of patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice