We carried out an announced comprehensive inspection at Roseneath Medical Practice in March 2018. We found that this service was not providing well-led care in accordance with the relevant regulations and we issued a Requirement Notice in respect of Regulation 17 (Good governance) of the Health and Social Care Act 2000. The full report for the comprehensive inspection can be found by selecting the ‘all reports’ link for Roseneath Medical Practice on our website at www.cqc.org.uk.

Following the comprehensive inspection the practice submitted an action plan, outlining the action they would take in order to comply with regulations. This inspection was an announced focused inspection, carried out on 25 October 2018 to confirm that the practice had effectively implemented their plan. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Roseneath Medical Practice provides a private GP and paediatrics service to patients. The practice is situated in premises which are shared with a dental practice, which is owned by the same partnership but did not form part of the inspection.

One of the partners is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Our findings were:

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

Our key findings were:

• There were formal arrangements in place to signpost patients to alternative sources of medical care when doctors at the practice were absent. We were told that when the GP was absent from the practice they would check and action incoming test results remotely; however, there were no safety netting arrangements in place to ensure that incoming test results requiring urgent action were processed in circumstances where the GP was unable to work (e.g. if they were unexpectedly very ill).
• Failsafe processes had been put in place to ensure that correspondence with, and about, patients conducted outside of the patient records system was promptly saved to the patient’s record.
• The practice followed GMC guidance in dealing with patients who did not consent for details of their care and treatment to be shared with their registered NHS GP.
• The practice had a clearly defined process for managing patient safety and medicines alerts, and maintained records of action taken in response to these.
• The practice monitored their service to ensure that care was delivered in accordance with guidance and best practice. They had carried out audits on re-calling patients for cervical screening and ensuring that patient records contained a comprehensive audit trail of all correspondence and actions taken.
• Processes were in place to remind patients that they were due for a routine cervical smear.
• Processes were in place to ensure that all staff kept up to date with the training required for their role.
• All clinical equipment was calibrated in order to ensure that it was working correctly.
• Arrangements had been put in place to allow patients to access language translation services where required.
• Appropriate operational policies were in place and were followed,
• Processes were in place to ensure that the practice knew the identity of patients, and checks were carried-out to ensure that adults providing consent to treatment on behalf of children had the authority to do so.

There were areas where the provider could make improvements and should:

• Include all members of clinical staff on the log of medicines and safety alerts to ensure a complete audit trail of alerts being read and actioned.
• Review the need for safety netting arrangements to ensure that incoming test results requiring urgent attention can be actioned in instances where clinicians are away from the practice and unable to check the system remotely.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We carried out an announced comprehensive inspection on 20 March 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was providing safe care in accordance with the relevant regulations; however, in some areas the service’s governance arrangements required review and improvement in order to ensure that they supported the delivery of safe care. The impact of our concerns is minor for patients using the service, in terms of the quality and safety of clinical care. The likelihood of this occurring in the future is low once it has been put right.

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations; however, in some areas the service’s governance arrangements required review and improvement in order to ensure that they supported the delivery of effective care. The impact of our concerns is minor for patients using the service, in terms of the quality and safety of clinical care. The likelihood of this occurring in the future is low once it has been put right.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that in some areas this service was not providing well-led care in accordance with the relevant regulations.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Roseneath Medical Practice provides a private GP service to patients. The practice is situated in premises which are shared with a dental practice, which is owned by the same partnership but did not form part of the inspection.

One of the partners is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Feedback received from speaking to patients and reviewing the CQC comment cards was positive about the service received. Patients commented that they felt confident in the clinical care they received and that they were given plenty of time during appointments.

Our key findings were:

• The practice had systems to manage risk; however, in some cases these systems required review in order to ensure that they were effective. When incidents did happen, the practice learned from them and improved their processes.
• The practice delivered care according to evidence- based guidelines; however, they did not have a process of quality assurance in order to monitor adherence to guidelines and to assess patient outcomes. The practice had not developed an effective process of evaluation to drive improvements to the quality of patient care.
• Staff involved and treated patients with compassion, kindness, dignity and respect; however, the practice did not have facilities in place to assist patients with communication needs, such as a hearing loop or access to language translators.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a focus on continuous learning and improvement at all levels of the organisation.

We identified regulations that were not being met and the provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

You can see full details of the regulations not being met at the end of this report.

There were areas where the provider could make improvements and should:

• Review and improve arrangements to assist patients with communication needs.
• Embed the newly revised recruitment to ensure that full records are kept, in particular, written records of references collected.
• Embed the newly introduced cleaning schedule and cleaning audit process.
• Embed and monitor the effectiveness of the newly introduced guidance on checks of patient identity and parental responsibility.