Background to this inspection
Updated
25 May 2018
Billesdon surgery is a practice which provides a range of primary medical services to 7009 patients from a main surgery in the village of Billesdon, 4 Market place, Billesdon, Leicestershire, LE7 9AJ and a branch surgery in Bushby, Hill Court, Main Street, Bushby, Leicestershire, LE7 9NY. Both sites were visited as part of the inspection.
The practices services are commissioned by East Leicestershire and Rutland Clinical Commissioning Group (CCG). The practice has a General Medical Services Contract (GMS) to deliver primary care services to local communities.
The practice is registered with the CQC to carry out the regulated activities of: Diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder and injury.
The service is provided by two full time male GP partners, two part time female GP partners, one part time salaried female GP and one part time locum GP who provide 33 sessions per week. There are also three practice nurses, one health care assistant, a dispensary manager and four dispensers. They are supported by a practice manager, a business manager, an IT manager and reception and administration staff.
The out of hours service is provided by Derbyshire Health United (DHU) between the hours of 8am and 8.30am and 6pm and 6.30pm. For hours between 6.30pm and 8am patients could phone 111 services.
All clinical areas across both sites are situated on the ground floor of the buildings and can be accessed easily. Parking is available at both sites, including spaces designated for use by people with a disability.
The practice offered dispensing services to those patients on the practice list who lived more than one mile (1.6km) from their nearest pharmacy. 3566 patients are eligible to receive the dispensing service which is 51% of registered patients.
The practice population demographics reflect those nationally except having a higher number of patients aged over 65. The practice falls within the 10th decile of deprivation which is much lower levels of deprivation compared to the average for practices in England.
Updated
25 May 2018
This practice is rated as Good overall. (Previous inspection October 2016 – Good with safe domain rated as requires improvement)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
We carried out an announced comprehensive inspection at Billesdon surgery on 26th April 2018 following up on previous breaches of regulations found in 2016.
In October 2016 the practice was issued with a requirement notice for the breach of regulation 12 for Safe care and treatment of the Health and Social care act. The regulation was not being met as the registered person did not do all that was reasonably practicable to assess, monitor, manage and mitigate risks to health and safety of service users. The practice needed to make improvements in systems to manage medications and review the repeat prescribing procedure for high risk medications.
At this inspection we found:
The practice had addressed all concerns that were identified at the previous inspection.
- The practice had clear systems to manage risk so that safety incidents were less likely to happen.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
- There was an emphasis on continuous learning and improvement at all levels of the practice. This included the significant event analysis, sharing and updating of policies, clinical audit and feedback from patients and staff.
- The practice implemented and monitored changes to ensure the patients’ needs were always met.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
- There were named accountable clinicians for areas of the practice and also non-clinical lead for patients with dementia or carers.
- The leadership structure was well embedded within the practice.
The areas where the provider should make improvements are:
- Review the process to ensure all safety alerts are received, recorded and acted upon.
- Review any missed appointments for children or vulnerable adults within secondary care documenting the response in all cases and act upon if required.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice