- GP practice
South Leicestershire Medical Group Also known as Dr M A Williams & Partners
All Inspections
20 June 2023
During a routine inspection
We carried out an announced focused inspection at South Leicestershire Medical Group on 20 June 2023. Overall, the practice is rated as requires improvement.
Safe - Requires improvement
Effective - Requires improvement
Caring – Not inspected, rating of good carried forward from previous inspection
Responsive - Requires improvement
Well-led - Requires improvement
Following our previous inspection on 28 April 2022 the practice was rated requires improvement overall and for all key questions but rated good in caring.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for South Leicestershire Medical Group on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection to follow up on concerns and breaches of regulation from a previous inspection in line with our inspection priorities.
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A short site visit.
- Staff questionnaires.
Our findings
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 found that:
- The practice did not always code safeguarding records effectively or deal with safeguarding tasks in a timely manner.
- Services within the dispensary were not always being delivered in line with regulations.
- Medicine reviews were not always effective or completed in a timely manner.
- Patients were not always able to access care and treatment in a timely way.
- Practice leaders were not always aware of poor performance within some areas of the practice.
- The practice did not operate effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
We found a breach of regulation. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
In addition there were areas the provider could improve and should :
- Continue to identify, contact and assess patients who are eligible for NHS health checks.
- Continue to review and improve the system and process to gain feedback from patients in relation to access.
- Document discussions had with patients in medical records in respect of risks associated from safety alerts.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services
28 April 2022
During a routine inspection
We carried out an announced inspection at South Leicestershire Medical Group on 28 April 2022. Overall, the practice is rated as requires improvement.
The ratings for each key question are:
- Safe - Requires improvement
- Effective - Requires improvement
- Caring - Good
- Responsive - Requires improvement
- Well-led - Requires improvement
Following our previous inspection on 19 November 2014, the practice was rated as Good overall and for all key questions. At this time, the practice was registered as Kibworth Health Centre, and this was prior to its merger with another local GP practice.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for South Leicestershire Medical Group on our website at www.cqc.org.uk
Why we carried out this inspection
This was a comprehensive inspection including all five key questions. Our inspection in April 2022 was undertaken as part of a wider review of urgent and emergency care systems in Leicester, Leicestershire and Rutland. The practice was selected for inclusion as we had some concerns about the high number of patient complaints received by the CQC in relation to access, and further to whistleblowing allegations received from staff.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a reduced amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing
- Completing clinical searches on the practice’s patient records system remotely and discussing findings with the provider
- Reviewing patient records remotely to identify issues and clarify actions taken by the provider
- Requesting evidence to be submitted from the provider prior to the site visit
- A short site visit
Our findings
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 Requires Improvement.
We found that:
- The practice did not always provide care in a way that kept patients safe and protected them from avoidable harm.
- Patients did not always receive effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Patients were not able to access care and treatment in a timely way.
- The way the practice was led and managed did not always promote the delivery of high-quality, person-centre care.
We saw the following example of outstanding practice:
- We found an organised and well-run dispensary. Dispensers’ qualifications at NVQ level 3 exceeded the requirement for level 2 NVQ. Dispensary staff had created end of life medication grab bags for any emergency needs, meaning that all injectables would be available at short notice, and made it easy for staff to locate the medicines required for swift dispensing. In adittion, as a result of a patient questionnaire and subsequent completion of dementia training, the dispensary team made small changes to their service, including making signs bigger for patients. Dispensary staff also devised a leaflet for patients following feedback from the questionnaire, to identify where medications could be safely disposed. This resulted in an increase of medications being returned to the dispensary, however patients were positive about the education they had received.
We found two breaches of regulations. The provider must:
- 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.
In addition, the provider should:
- Ensure that the ongoing review of telephone access and appointment availability is maintained to make further improvements to enhance patient experience and improve patient access.
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
19 November 2014
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Kibworth Health Centre on 19 November 2014. Overall the practice is rated as good.
Specifically, we found the practice to be good for providing well-led, effective, caring, safe and responsive services.
Our key findings across all the areas we inspected were as follows:
- Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
- Risks to patients were assessed and well managed.
- Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
- Patients said 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 relatively easy to make an appointment with a named GP and that there were different surgeries available depending on the patient’s location.
- 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.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
30 May 2014
During an inspection looking at part of the service
Prior to this inspection we received information of concern regarding the appointment system and referral systems in place at the practice.
As part of the inspection we visited all three surgery locations, Main Street Great Glen, Fleckney Medical Centre High Street Fleckney and Kibworth Health Centre.
At this inspection we spoke with the practice manager, the pharmacy manager, the nurse manager, an advanced nurse practitioner provided by an agency, an administration secretary and a receptionist. We also spoke with three patients and looked at policies and procedures.
The patients we spoke with during our visit were dissatisfied with the appointment system but were happy with all other aspects of the service they received from the practice. One patient we spoke with told us, 'I find the appointment system quite impossible at times, I think it's a national problem.' Another patient said, 'They are really efficient with referrals and you get a timely response.'
We found that the provider had taken steps to carry out the required improvements since our last visit, however we found there were no systems in place to monitor the quality of the cleaning carried out. We also found the practice did not have an infection control policy. This meant the provider did not have the necessary systems in place to ensure patients and others were protected from the risks of healthcare associated infections.
23, 24 October 2013
During a routine inspection
Patients were generally very positive about their experiences. They told us they could normally get an appointment within 48 hours and that the on-line booking system was also helpful. They also told us reception staff were polite and helpful.
Medicines and vaccines were stored and dispensed appropriately.
The provider had systems in place for monitoring the quality of service provision, the PPG are active and have developed a questionnaire to be distributed to patients.
We found some areas of improvement were required to prevent the possibilities of cross infection and cross contamination at the practice.