We carried out an announced comprehensive inspection at Redwood House Surgery on 20 March 2019 as part of our inspection programme. The practice registered with the CQC in April 2018 and this was their first comprehensive inspection.

We based our judgement of the quality of care at this service 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 good overall and for all population groups.

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

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• 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.

We rated the practice as requires improvement for providing well-led services because:

• Governance arrangements were not effective for monitoring patients on high risk medicines and repeat medicines.
• Staff training had been inconsistently reviewed to ensure all staff had received essential training such as fire safety, health and safety, infection control and mental capacity act.

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).

The areas where the provider should make improvements are:

• Review the recall process for women eligible for cervical screening to ensure uptake.
• Review the January 2019 intercollegiate guidance for children’s safeguarding and offer additional training to staff to attain the appropriate level, where neccessary.
• Review the process for monitoring and reporting uncollected prescriptions.
• Consider how improvements could be made following patient feedback about accessibility and appointments.

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