Background to this inspection
Updated
27 May 2021
Spirit Healthcare Ltd. has been the registered provider for Beaumont Leys Health Centre since October 2017.
Beaumont Leys Health Centre is located at 1 Little Woods Close, Leicester. LE4 0UZ. The premises is purpose-built health centre. Beaumont Leys Health Centre is one of four GP practices run by Spirit Healthcare Ltd.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.
The practice is part of the NHS Leicester City CCG and delivers Alternative Provider Medical Services (APMS) to a patient population of 7,181. This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices called City Care Alliance Primary Care Network
Information published by Public Health England, rates the level of deprivation within the practice population group as 260 out of a maximum of 6,900, indicating they are in a more deprived area. Deprivation rankings area at England level, the lower the number the more deprived the practice or CCG is relative to others.
The National General Practice Profile states that 65% of the practice population is from a white background and 14% from an Asian background, 14% black and 7% from a mixed or non-white background.
There is a team of four salaried GPs, a practice nurse and one advanced nurse practitioner who work at the practice. The clinicians are supported by a practice manager alongside reception staff. Spirit Healthcare have a centralised administration team who provide back office support to the three locations based in Leicester.
The practice is open Monday, Wednesday, Thursday and Friday 8am to 6.30pm. Tuesday 7am to 6.30pm and patients were being asked to call the practice to make an appointment.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered an appointment.
The practice has opted out of the requirement to provide GP consultations when the surgery is closed. Out- of-hours services are provided by Derbyshire Health United, which is accessed via the NHS 111 service.
Updated
27 May 2021
We carried out a desktop follow up inspection at Beaumont Leys Health Centre on 21st April, 28th April and 4th May 2021 and focussed on the breaches of regulations following an inspection on 30 October 2019 under the following key question and population group.
The practice was inspected on 30th October 2019 and was rated Good overall with a rating of Requires Improvement in the Safe key question and the population group of Working Age People. Effective, Caring, Responsive, Well-led and the population groups of Older People, People with Long Term Conditions, Families, Children and Young People, People whose circumstances may make them vulnerable and People experiencing poor mental health (including people with dementia) were rated as Good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Beaumont Leys Health Centre on our website at www.cqc.org.uk
Why we carried out this review
This inspection was a review of information without undertaking a site visit inspection to follow up on breaches of Regulations 12 – Safe Care and Treatment and Regulation 17 – Good Governance.
This inspection focused on aspects relating to recruitment, staff immunisation records and cytology screening
We also reviewed the processes for health and safety, chaperoning of patients, uptake of childhood immunisations and patient experience in particular telephone and appointment access.
How we carried out the inspection/review
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 reviews differently.
This review was carried out remotely and therefore we did not spend any time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included: -
- Requesting evidence from the provider
- Clarification of evidence with the provider
Our findings
We based our judgement of the quality of care at this service on a combination of:
- what we found when we reviewed the evidence sent by the provider
- information from our ongoing monitoring of data about services and information from the provider, patients, the public and other organisations.
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At this inspection the practice remained Good overall, the breaches of regulation were met but the practice remains Requires Improvement for Safe services because:
- A system was now in place for staff recruitment and retention
- Records were now kept in regard to staff immunisations
- Chaperone policy was in place which gave guidance to staff.
- We found that the management team continued to liaise and work closely with Leicestershire Partnership Trust to ensure health and safety issues identified were followed up and acted on in a timely manner where possible. However, there were still a number of actions that had been outstanding for two to three years that still needed to be addressed.
- Improvements had been made so that people were able to access care and treatment in a timely way.
The rating for the population group of Families, Children and Young People is rated as Good because:-
- The practice had continued to carry out child immunisation throughout lockdown. Unverified data demonstrated improvements in all five childhood immunisation uptake indicators but further work was required.
The rating for population group of Working Age People (including those recently retired and students) remains as Requires Improvement because:
- The percentage of women eligible for cervical cancer screening at a given point in time who were screened adequately within a specified period was still below 70% and below the national target of 80%.
Whilst we found no breaches of regulations, the provider should:
- Continue to monitor and make improvements to the childhood immunisation uptake.
- Promote and drive the uptake of cervical screening programmes with patients registered at the practice.
- Continue to liaise and work closely with Leicestershire Partnership Trust to ensure health and safety issues identified are followed up and acted on in a timely manner.
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