The Care Quality Commission
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Archived: Rosegarth Surgery

Overall: Good read more about inspection ratings

Rothwell Mount, Halifax, West Yorkshire, HX1 2HB (01422) 353450

Provided and run by:
Rosegarth Surgery

All Inspections

7 December 2021

During an inspection looking at part of the service

We carried out an unannounced inspection at Rosegarth Surgery on 7 December 2021. This inspection was focused on the management of access to appointments.

This inspection did not affect ratings, and therefore the overall rating for the practice remains rated as Good.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Rosegarth Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was undertaken in response to information we received which suggested potential issues with access to appointments.

How we carried out the inspection

The inspection was led by a CQC lead inspector who spoke with staff during a site visit.

Interviews were carried out with the practice business manager, operations and data quality manager and reception manager.

We found that:

  • The practice had withstood a number of recent losses to their staffing contingent. They had adapted their delivery model in accordance with these staff changes.
  • Patients had the option of contacting the practice online, by telephone or in person.
  • Available appointments were allocated in equal proportion to accommodate both urgent and routine consultations.
  • An updated telephone system enabled the practice to collate relevant data to support the monitoring and oversight of telephone usage by patients.

Whilst we found no breaches of regulations, the provider should:

  • Update the practice website to accurately reflect the current options for patients in relation to appointment availability and practice opening times.
  • Continue to recruit to vacant posts to complete the staffing complement for the service.

Details of our findings and the evidence supporting our judgements are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

9 January 2018

During a routine inspection

This practice is rated as Good overall. The practice was previously inspected on 21 April 2015. On that occasion the practice received a rating of Outstanding overall, with ratings of Good for providing safe, caring and well led services; and Outstanding for providing effective and responsive services.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Rosegarth Surgery on 9 May 2018, as part of our inspection programme.

At this inspection we found:

  • The practice had an open and transparent process for dealing with safety incidents and near misses. When incidents occurred the practice learned lessons and made changes to improve processes and reduce risks when possible.
  • There were clear governance policies and protocols which were accessible to all staff.
  • The practice had carried out a ‘Perfect Day’ exercise internally. This enabled them to articulate what would improve the patients’ journey through the service, as well as enhancing staff experience. They had plans to implement changes in line with this. For example, they were establishing new systems for patients to access their test results in a timely and appropriate way
  • The practice undertook quality improvement activity to review and improve the effectiveness and appropriateness of care provided. Care and treatment was delivered in line with current evidence based guidance.
  • The practice had achieved Gold accreditation from the Gold Standards Framework for palliative care. Seventy five percent of identified patients had been appropriately monitored prior to their death using this framework. This was an increase from 36% of patients before accreditation training had been undertaken.
  • The practice endeavoured to provide continuity of care for patients, with access to the clinician of their choice whenever possible. Patient feedback in relation to access to appointments and the quality of care provided was generally positive.
  • We observed staff treating patients with kindness and compassion.
  • The leadership team was approachable and visible. Staff told us they felt supported in their role. Practice developments and initiatives were designed to improve patient experience in accessing care.

The areas where the provider should make improvements are:

  • Review staff immunisation status in line with Department of Health recommendations.
  • Complete staff appraisals and development plans in a timely way.

21 April 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Rosegarth Surgery on 21 April 2015. Overall the practice is rated as outstanding.

Specifically we found the practice was outstanding for providing effective and responsive services for older people and people whose circumstances may make them vulnerable. We found the practice to be good for providing safe, caring and well-led services. It was also good for providing services for people with long term conditions, families, children and young people, working age people (including those recently retired and students) and people experiencing poor mental health (including people with dementia).

Our key findings were as follows:

  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and were involved in care and decisions about their treatment. Information was provided to help patients understand the care available to them.
  • Risks to patients were assessed and well managed.
  • Staff understood and fulfilled their responsibilities to raise concerns and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients.
  • The practice had a clear vision that had improvement of service quality and safety as its top priority. There was good evidence of effective team working.

We also found areas of outstanding practice:

  • The practice had employed an advanced nurse practitioner (ANP) to case manage registered patients who were resident across nine local care homes. As a consequence, over a 12 month period there had been a 20% reduction in unplanned hospital admissions and a decrease in the length of stay for an admission. There was evidence of multidisciplinary working with the care homes, local district nursing teams and secondary care, this was supported by the use of shared care plans. The ANP also provided education and support to the staff who worked within those care settings. This had enabled those staff to feel more confident about caring for those patients, especially in relation to end of life care.
  • The practice had a comprehensive system for identifying and supporting patients who had a learning disability. They used an individualised ‘my health action plan’ with all those patients. The plan was individualised to each patient and contained personal details, name of their GP and specific information, for example what the patient liked to be called.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice