The Care Quality Commission
  • Doctor
  • GP practice

Archived: Beaumont Leys Health Centre

Overall: Good read more about inspection ratings

1 Little Wood Close, Leicester, Leicestershire, LE4 0UZ (0116) 235 0435

Provided and run by:
Spirit Healthcare Ltd

Important: The provider of this service changed. See new profile
Important: The provider of this service changed. See old profile

All Inspections

28th April and 5 May 2021

During an inspection looking at part of the service

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.

  • Safe
  • Working Age People.

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.

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

30 October 2019

During a routine inspection

We carried out an announced comprehensive inspection at Beaumont Leys Health Centre Surgery on 30 October 2019 as part of our inspection programme.

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 and good for the population groups of older people, long-term conditions, families, young people and children, people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia). We rated the population group for working age people (including those recently retired and students) as requires improvement.

We rated the practice as requires improvement for providing safe services because:

  • The provider chaperone procedure did not provide staff with appropriate guidance on where they should position themselves when carrying out the role of a chaperone.
  • Staff recruitment practices were not consistently followed and there were gaps in the staff recruitment documents available in staff files.
  • There was a lack of records to demonstrate that the provider had ensured that all staff were up to date with immunisations relevant to their role.

We rated the practice as good for providing effective, caring, responsive and well led services. We found that:

  • The practice had clear systems to manage risks so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • Patients received care and treatment that met their needs. However, the practice uptake for childhood immunisations in three of four indicators and cytology screening were below the national minimum uptake and the national targets.
  • The level of patient satisfaction had improved at the practice and improvements were seen on the previous year’s national patient GP survey results. However, patient satisfaction with the overall experiences of the practice remained low.
  • The practice organised and delivered services to meet patients’ needs. 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-centre care.
  • Services were tailored to meet the needs of individual patients. They were delivered in a flexible way that ensured choice and continuity of care.
  • There were innovative approaches to providing integrated person-centred care.
  • The practice had identified areas where there were gaps in provision locally and had taken steps to address them.

The areas where the provider must make improvements are:

  • Care and treatment must be provided in a safe way for service users.
  • Persons employed for the purposes of carrying on a regulated activity must be fit and proper persons.

The areas where the provider should make improvements are:

  • Review the chaperone procedure so that staff have clear guidance on where they should position themselves when carrying out the role of a chaperone.
  • 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.
  • Continue to monitor and improve the uptake of childhood immunisations.
  • Continue to monitor and improve patient experiences with staff, telephone access to appointments and satisfaction with the type of appointments offered at the practice.

(Please see the specific details on action required at the end of this report).

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