We carried out a review of the data available to us about Roseheath Surgery Ltd 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 Roseheath Surgery Ltd, you can give feedback on this service.
We carried out an announced focused review of Roseheath Surgery Ltd on 14 June 2021. Overall, the practice is rated as Good.
Following our previous inspection on 6 November 2019, the practice was rated Good overall and Requires Improvement for providing Well-led services. We also rated the population group working age people (including those recently retired and students) as Requires Improvement.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Roseheath Surgery Ltd on our website at www.cqc.org.uk
Why we carried out this review
We carried out this review to assess if the provider had addressed the Requirement Notice issued at the last inspection which indicated that systems and processes needed to be in place to ensure Patient Group Directives (PGDs) were appropriately authorised.
At the last inspection we rated the population group working age people (including those recently retired and students) within the Effective key question as Requires Improvement and advised the provider that they Should continue to work towards improving cervical cancer screening uptake as the screening data was not meeting the national coverage target. At this review we assessed the action the provider was taking to address this.
At the last inspection we advised the provider that they Should identify a Freedom to Speak Up Guardian and ensure that staff are familiar with who this is and their contact details. At this review we assessed the action the provider was taking to address this.
This review focussed only on evidence relating to the previous breach to regulations and other recommendations made following our last inspection. Therefore it only updated the ratings for the well led key question and working age population group. All other key question and population group ratings remain the same as following the previous inspection.
How we carried out the review
This focused review was a follow-up review of information without undertaking a site visit. Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our reviews differently. This review was carried out in a way which enabled us not to spend time on site.
This included:
Our findings
We based our judgement of the quality of care at this service on a combination of:
The practice continues to be rated as Good overall. The practice is now rated as Good for providing Well-led services and Good for the population group working age people (including those recently retired and students).
We found that:
Whilst we found no breaches of regulations, the provider should:
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
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:
Because of the assurance received from our review of information we carried forward the ratings for the following key questions:
We based our judgement of the quality of care at this service on a combination of:
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:
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:
The area where the provider must make improvements are:
(Please see the specific details on action required at the end of this report).
The areas where the provider should make improvements:
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
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 www.cqc.org.uk
Our key findings were as follows:
The practice had addressed the issues identified during the previous inspection.
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.
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:
However, there were also areas of practice where the provider needs to make improvements.
Importantly, the provider must:
In addition the provider should:
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice