Previously we carried out an announced comprehensive inspection at Rooksdown Practice on 22 January 2019 to follow up on breaches of regulations identified at a previous inspection in January 2018.

We served warning notices to the provider following breaches of regulations 17 Good governance, 18 Staffing and 9, Person centred care, of the Health and Social Care Act 2008. We also issued a requirement notice in relation to regulation 12, Safe care and treatment. Following our inspection in January 2019, the practice was rated as inadequate overall and placed into special measures.

We carried out an announced focused follow-up inspection at Rooksdown Practice on 15 March 2019 to to confirm that the practice had met the legal requirements in relation to the warning notices served after our previous inspection in January 2019. This report covers our findings in relation to those warning notices only.

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.

At this inspection we found that governance systems remained ineffective such that the provider had not fully assessed addressed the concerns identified. We have served a further Warning notice in relation to regulation 17, Good Governance.

We found that:

• Improvements in fire safety had been made but these were not yet embedded.
• The practice did not have an effective system to ensure all policies were updated and reflected current guidelines.
• The practice’s system for ensuring medicines and equipment were checked to ensure they were safe to use was not embedded in practice.
• There was limited monitoring of the outcomes of care and treatment.
• Services did not always meet patient needs.
• The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
• Systems to ensure patient dignity were not consistently maintained.

The areas where the provider must make improvements are:

• Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences.

• Ensure care and treatment is provided in a safe way to patients.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The full report published on 29 March 2019 should be read in conjunction with this report. The practice remains in special measures until a full comprehensive inspection is carried out by the Care Quality Commission. Therefore, the overall rating remains inadequate.

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

Rosie BenneyworthChief Inspector of General Practice

We carried out an announced comprehensive inspection at Rooksdown Practice on 22 January 2019.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 17 January 2018. Specifically, it was previously identified that systems were not formalised to ensure that there was overall governance, leadership and quality improvement across the practice and the branch.

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 inadequate overall.

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

• The practice’s processes for fire safety did not minimise risk.
• Not all staff had received safeguarding training appropriate to their role.
• A comprehensive infection prevention and control audit had not been conducted for the branch site.
• The practice’s system for ensuring medicines and equipment were checked to ensure they were safe to use were not effective and embedded in practice.

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

• There was limited monitoring of the outcomes of care and treatment.
• The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
• The practice was unable to show that it always obtained consent to care and treatment.

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

• The practice was unable to evidence the number of carers it identified.
• No actions had been identified to improve low survey results.

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

• Services did not always meet patient needs.
• Complaints were not always handled in line with their complaints procedure and they were not always used to improve the quality of care.

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

• The practice culture did not effectively support high quality sustainable care.
• The overall governance arrangements were ineffective.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• The practice did not always act on appropriate and accurate information.
• We saw little evidence of systems and processes for learning, continuous improvement and innovation.

The issues found in effective and responsive affected the rating of all population groups so we rated all population groups as inadequate.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients
• Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment

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

The areas where the provider should make improvements are:

• Use patient feedback to help drive improvements.
• Identify patients who are carers and provide appropriate support.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This practice is rated as Requires Improvement overall. (Previous inspection 06/2017 – Requires Improvement).

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. As the overall rating is requires Improvement the population groups are rated as:

Older People – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those recently retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people with dementia) - Requires Improvement

We carried out an announced focused inspection at the Rooksdown Practice on 17 January 2018. This inspection was conducted to follow up on breaches of regulations that were found in the previous inspection, which were related to the responsive and well led domains. We also reviewed areas where we made recommendations for improvement.

Cedar Medical Limited as the provider, since our last inspection in June 2017, changed one location known as The Beggarwood Surgery to become a branch of Rooksdown Practice. The patients list had merged in August 2017 and the registration amended in January 2018. A full comprehensive inspection had been carried out at The Beggarwood Surgery in February 2017 and had been placed into special measures and remained in special measures following reinspection in November 2017.

We inspected The Beggarwood Surgery as a branch as part of this inspection of Rooksdown Surgery.

At this inspection we found:

• Structures, processes and systems to support good governance and management were newly in place and not yet embedded for the management of the needs of both the location and the branch as one service.
• It was noted that there were two separate website addresses one for Rooksdown Practice and one for The Beggarwood. Surgery. This would suggest the new vision of one practice had not yet been imbedded and could cause confusion for communicating with patients.
• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines. However clinical audit to improve on quality of care and outcomes for patients was not yet established as a programme to include the location as well as the branch.
• Risks to patients were assessed and mostly well managed.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patient involvement was limited, although there was a patient participation group and the practice was working to re-launch the group.
• There was a focus on continuous learning and improvement at all levels of the organisation.
• The provider was aware of the requirements of the duty of candour.

The areas where the provider must make improvements are:

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

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Rooksdown Practice on 21 July 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for Rooksdown Practice on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 30 June 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 21 July 2016. We carried out a comprehensive inspection because the practice was rated inadequate for provision of well led services at the previous inspection. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Whilst the practice demonstrated improvement in provision of safe and effective services we identified further breaches of regulation resulting in ratings of requires improvement for provision of responsive and well-led services. Overall the practice remains rated as requires improvement.

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. The documentation of significant events was comprehensive. However, the learning from incidents was not always detailed in minutes of meetings where the events were reviewed. Staff who were unable to attend meetings would not always receive the learning from and how to avoid recurrence of significant events.
• The practice had an audit plan and there was some evidence that audits were driving improvements to patient outcomes. However, the audit plan was not always followed as some audits identified for a second cycle were overdue.
• The majority of patients said they were treated with compassion, dignity and respect.
• Information about services was available and the practice was active in obtaining information in Polish for the 13% of patients registered of this nationality.
• The practice had a number of policies and procedures to govern activity. However, it was not always clear when these were due for review.
• Risks to patients were assessed and mostly well managed.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on. A patient participation group had formed in the last year and met regularly.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvements are:

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

• Establish and maintain systems and processes that seek and act on feedback from relevant persons and other persons on the services provided in the carrying on of the regulated activity, for the purposes of continually evaluating and improving such services.

In addition the provider should:

• Ensure arrangements are in place to undertake appropriate follow up of patients diagnosed with depression.
• Review and update procedures and guidance.
• Review the feedback from patients in regard to the customer care offered by some reception staff.
• Review and act upon feedback from patients in regard to specific aspects of the care provided.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Rooksdown Practice on 21 July 2016. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. However, learning from incidents had not always been shared with staff at the practice.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Most patients spoken to on the day, and all comment cards received from patients stated they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it difficult to make an appointment with a named GP and felt that continuity of care had been interrupted due to a high turnover of GPs. Patients reported that they did not know who their named GP was as they had left the practice.
• Urgent appointments were available on the same day.
• The practice was operating out of a temporary building and had been equipped to treat patients and meet their needs. However, the building was not practical for the volume of patients or during periods of hot weather.

• There was a documented leadership structure and most staff felt supported by management but at times they weren’t sure who to approach with issues.

• The practice did not provide us information about how they engage with the patient participation group (PPG) and there was no representative available to talk to on the day of inspection.

• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Ensure systems in place to monitor effectiveness, quality and safety of the practice are sufficiently embedded and used to mitigate the risk of harm to patients and drive improvement. In particular: complaints handling and significant event management. Ensure learning points identified as a result of complaints or significant events are acted upon and monitored to include reference to the duty of candour when identified.

• Ensure arrangements to manage long term conditions for patients are effective and patients are enabled to have health reviews.

• Ensure policies related to the running of the practice are suitably maintained, up to date and accurate.

The areas where the provider should make improvement are:

• Review systems to monitor and record the number of carers at the practice.

• Review arrangements to ensure patient information is readily available to patients in their preferred language.

• Review arrangements in order that the practice can be reassured that sharps bins are labelled and disposed of in accordance with infection control guidance.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice