The Care Quality Commission
  • Doctor
  • GP practice

The Central Surgery

Overall: Good read more about inspection ratings

Brooksby Drive, Oadby, Leicester, Leicestershire, LE2 5AA (0116) 271 2175

Provided and run by:
The Central Surgery

All Inspections

14 December 2023

During a routine inspection

We carried out an announced comprehensive inspection at The Central Surgery on 14 December 2023. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive – Requires improvement.

Well-led - Good

Following our previous inspection on 7 March 2022, the practice was rated good overall and for all key questions but requires improvement for providing well-led services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Central Surgery on our website at www.cqc.org.uk

Why we carried out this inspection.

We carried out this inspection to follow up breaches of regulation from a previous inspection and 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 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.
  • Patients could not always access care and treatment in a timely way.
  • At the previous inspection we found some systems and processes were not effective for example, the supervision of non-medical prescribers. At this inspection we found the way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

  • Continue to engage with the population to improve the uptake of cervical screening and childhood immunisations.
  • Continue to identify, contact and assess patients who are eligible for NHS health checks including patients with learning disabilities.
  • Act upon findings from risk assessments to ensure a safe environment for staff and the patient population. Including following up on infection prevention and control concerns identified during the inspection.
  • Continue to engage with patients to obtain feedback in order to improve patients experience of the service. Including encouraging the development and uptake in the Patient Participation Group (PPG).

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 Health Care

7 March 2022

During a routine inspection

We carried out an announced inspection at The Central Surgery on 7 March 2022. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led – Requires Improvement

We last inspected on 27 October 2016, the practice was rated Good overall and for all key questions:

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Central Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on potential risks relating to access.

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 minimum 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 and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • 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 Good overall

We found that:

  • The practice had been though a very difficult time during the last 18 months. In addition to the challenge arising from the COVID-19 pandemic, the practice partnership had reduced from four GPs to one (due to personal reasons and relocation out of the area) and had amicably separating from a merger with another practice due to differing patient needs. The remaining partner and staff team have worked hard to ensure services continued.
  • Under challenging circumstances the principal GP showed strong leadership, with clear evidence of innovation. Through participation in the General Practice Improvement Leads Scheme the practice was working to deliver a more sustainable service going forward, focussing on capacity and demand, skill mix and signposting.
  • We found systems in place to keep patients safe and protect them from avoidable harm, including support for some of the practices most vulnerable patients and systems to learn from incidents and complaints.
  • The practice had implemented additional measures to safeguard patients and staff from the risk of COVID-19 infection and had secured funding to help refurbish the premises.
  • The practice had effective systems for supporting patients to live healthier lives, this included active signposting and specialist support available.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • However, what was not always clearly demonstrated during the inspection was the evaluation of the impact of changes, clear systems for monitoring of performance and potential risks.
  • Our review of clinical records found patients on medicines which needed regular review due to potential risks received follow up and monitoring. However, we did identify some areas where improvements were needed in particular the follow up of medicine safety alerts to minimise the risks to patients taking them.
  • Our review of clinical records found patients with long term conditions received follow up although in some cases this was not always provided in a timely way.
  • The practice was not consistently meeting national targets for all child immunisations and cervical cancer screening programmes.
  • Staff received support and training for their roles. Supervision of non-medical prescribers was in place but did not extend to formal reviews of consultations and prescribing.
  • The practice was involved in improvement activities.
  • Information from patients gave mixed feedback about access to appointments.

We found a breach of regulations. The provider must:

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

Whilst we found no breaches of regulations, the provider should:

  • Follow up staff vaccinations where not in line with recommended government guidance.
  • Maintain effective systems for ensuring staff training is completed in a timely manner.
  • Improve uptake of cervical screening and child immunisations.

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

20 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Central Surgery on 20 September 2016. Overall the practice is rated as good.

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

  • There was an effective system in place for reporting and recording significant events and lessons were shared to make sure action was taken to improve safety in the practice.

  • The practice carried out an annual review of incidents to identify themes and take action to improve patient services.

  • The practice monitored prescribing data provided by the local clinical commissioning group and took action as appropriate to ensure prescribing was in line with best practice guidance.

  • There was a comprehensive business plan in place in the event of a major incident or disruption to the service.

  • The practice actively discussed new and updated NICE guidance to ensure practice was in line with current guidance.

  • The practice actively carried out clinical audits to demonstrate quality improvement.

  • The practice supported patients to live healthier lives.

  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

  • Information for patients about the services available was easy to understand and accessible.

  • The practice actively reviewed the number of appointments available to ensure demand could be met in line with national guidance.

  • Patient feedback stated patients were generally happy with the appointment system and got an appointment when they needed one. However, 12 comment cards we received expressed difficulties at times in accessing the service. This information was reflected in the most recent national GP survey results and the practice had implemented an action plan to improve access and patient satisfaction.

  • The practice had a clear vision to provide excellence, compassionate, personalised NHS care our the community.

  • The practice had a number of policies and procedures to govern activity and had an established meeting structure to discuss governance issues.

  • The provider was aware of and complied with the requirements of the duty of candour. The partners encouraged a culture of openness and honesty.

  • The practice sought feedback from staff and patients, which it acted on, including national survey results.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

18 June 2015

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at Drs Davies, Hadley, Kuncewicz, Cook & Jameson (also known as The Central Surgery) on 18 June 2015 in order to look into concerns which had been raised with the Care Quality Commission about the service. As this was a focused inspection and the practice had not been inspected before we were unable to rate the practice.

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.
  • Patients said they felt safe and were treated with compassion, dignity and respect.
  • Patients said they usually found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • In January 2015 the national patient survey showed that out of 118 patients that responded 85% described their overall experience of the practice as good and 98% had confidence or trust in the last GP they spoke with.
  • There were sufficient staff with the right skill mix to provide a safe service.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a robust system in place to deal with incoming pathology results appropriately and in a timely manner.
  • There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.
  • The GPs and long term locum practice managers took an active leadership role for overseeing that the systems in place to monitor the quality of the service were consistently being used and were effective.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

  • Update the practice safeguarding policies to include details of the lead and ensure all staff are aware who the lead is.
  • Ensure patient group directions (PGDs) are in place and signed by relevant staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice