We carried out an announced comprehensive inspection at Ratby Surgery on 4 April 2019 as part of our inspection programme.

Our judgement of the quality of care at this service is based 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.

We have rated this practice as requires improvement overall.

We rated the practice as inadequate for providing safe services because:

• The practice did not always have clear systems and processes to keep patients and staff safe.
• Systems to support appropriate standards of cleanliness and hygiene were not in place.
• The system for recording and acting on safety alerts was not effective.

We rated the practice as good for providing effective, caring and responsive services because:

• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way and feedback received from patients was overwhelmingly positive.

We rated the practice as requires improvement for providing a well led service because:

• Some governance systems were not being operated effectively.
• The practice did not have clear and effective processes for managing risks.

We rated all population groups as good.

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

In addition, the provider should:

• Improve the system for significant events to include a review of events to ensure actions implemented are effective.
• Implement the planned formal system to ensure competence of clinical staff.
• Consider including a neonatal pulse oximeter in their emergency equipment.
• Obtain evidence of vaccination status for those staff for whom it was not available at the time of inspection.
• Embed the new process for monitoring data in respect of the cold chain.

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