Aylestone Health Centre

We carried out an announced inspection at Aylestone Health Centre on 27 April 2022. Overall, the practice is rated as Requires Improvement.

Set out the ratings for each key question

Safe - Good

Effective – Requires Improvement

Caring - Good rating from previous inspection carried over

Responsive - Good rating from previous inspection carried over

Well-led – Requires Improvement

Following our previous inspection on 11 June 2018, 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 Aylestone Health Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Leicestershire and Rutland. To understand the experience of GP providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

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 Requires Improvement overall

We found that:

• Safeguarding registers needed strengthening to ensure all information discussed through a multi-disciplinary approach were recorded in the patients’ records.
• The practice was unable to demonstrate effective systems were in place for the recruitment of staff.
• The practice were unable to provide assurances that there was a system in place to ensure notes were summarized in a timely manner. On reviewing a random sample of notes we found records dated from January 2021, that were still awaiting summarising.
• We were told that care plans were in place for patients on the palliative care register. On reviewing a random sample of records we found no documented care plan available within the clinical records.
• Governance processes were ineffective to minimise risk. For example: The practice had some systems in place to monitor staff who carried out advanced clinical practice roles, however this did not cover all clinical roles.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
• The practice had an active patient participation group that supported the leadership team in health care initiatives.

We found breaches in regulations. The provider must:

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

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