During an assessment under our new approach
Date of Assessment: 24 April 2025 to 21 July 2025. De Montfort Surgery is a GP practice and delivers service to around 21,000 patients under a contract held with NHS England. The practice is one of eight locations which is managed by the provider Willows Health Ltd across Leicestershire. The National General Practice Profiles states that its patient population has mixed ethnicity that is 52% White, 25% Asian, 13% Black, 5% other and 5% Mixed. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the fifth decile (5 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report. Our review of clinical records indicated that generally patients received safe care and treatment. Where some patients were overdue monitoring, the practice could demonstrate they had tried to contact the patients and had processes in place to ensure they continued to receive safe care. The practice strived to be a learning organisation however some minor incidents and complaints had not always been investigated, and learning was not always shared with all staff. Whilst the premises was visibly clean, the practice did not always have oversight of risks that had been identified and if action had been taken by the landlord to address these. There were processes in place to ensure suitable staff were hired, and oversight of training was well managed however there was a lack of administration staff at the time of our inspection which had created a backlog in some areas of work. People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth referrals when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people to make decisions in their care where they did not have capacity. People were treated with kindness and compassion. Staff protected their privacy and dignity. We found times where patients concerns were not listened to. Staff reported that their feedback was not always listened to and did not always feel like managers supported staff wellbeing. People were involved in decisions about their care. The service provided information people could understand. When patients gave feedback, it was not always recorded and acted upon in line with the providers expectations. Patient feedback suggested that the service was not easy to access, and some patients could not access appointments as easy as others. When appointments were full, they were told to access 111 services rather than offered support. There was not a shared culture across the provider and the practice. Some governance policies were in place however not always in line with the practices working. We found that some governance systems did not give assurance that the practice ensured patients data was safely transferred. Staff did not always feel that managers listened to them when they gave feedback. The practice had begun working with its population to deliver services in line with their needs; however, work was ongoing with some difficult to reach populations. There was some evidence of audits being completed at provider level, however further cycles were needed to demonstrate impact on patients at the practice.