Updated
16 November 2016
Letter from the Chief Inspector of General Practice
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.
-
Medicine refrigerators were checked and reset on a daily basis.
-
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.
-
Systems and processes relating to infection control in line with national guidance were put in place, including
actions from infection control audits being recorded and implemented.
-
All necessary employment checks for staff were undertaken, including DBS checks.
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Formal governance arrangements were in place, including systems for assessing and monitoring risks, for example relating to legionella and fire safety arrangements.
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Staff had received an annual appraisal.
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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:
-
Further embed the process which has been introduced to
ensure emergency equipment, other equipment and medicines are checked as per the practice protocol.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
People with long term conditions
Updated
16 November 2016
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
Following this most recent inspection we found that overall the practice was now rated as good and significant improvements had been made specifically, the ratings for providing a safe and well led service. These rating applied to everyone using the practice, including this population group
The practice is now rated as good for the care of people with long-term conditions.
Families, children and young people
Updated
16 November 2016
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
Following this most recent inspection we found that overall the practice was now rated as good and significant improvements had been made specifically, the ratings for providing a safe and well led service. These rating applied to everyone using the practice, including this population group
The practice is rated as good for the care of families, children and young people.
Updated
16 November 2016
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
Following this most recent inspection we found that overall the practice was now rated as good and significant improvements had been made specifically, the ratings for providing a safe and well led service. These rating applied to everyone using the practice, including this population group
The practice is now rated as good for the care of older people.
Working age people (including those recently retired and students)
Updated
16 November 2016
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
Following this most recent inspection we found that overall the practice was now rated as good and significant improvements had been made specifically, the ratings for providing a safe and well led service. These rating applied to everyone using the practice, including this population group.
The practice is now rated as good for the care of working-age people (including those recently retired and students).
People experiencing poor mental health (including people with dementia)
Updated
16 November 2016
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
Following this most recent inspection we found that overall the practice was now rated as good and significant improvements had been made specifically, the ratings for providing a safe and well led service. These rating applied to everyone using the practice, including this population group
The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).
People whose circumstances may make them vulnerable
Updated
16 November 2016
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
Following this most recent inspection we found that overall the practice was now rated as good and significant improvements had been made specifically, the ratings for providing a safe and well led service. These rating applied to everyone using the practice, including this population group
The practice is now rated as good for the care of people whose circumstances may make them vulnerable.