The Care Quality Commission
  • Doctor
  • GP practice

Archived: Rushey Mead Health Centre

Overall: Good read more about inspection ratings

8 Lockerbie Walk, Leicester, Leicestershire, LE4 7ZX (0116) 323 2020

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

All Inspections

19, 27 and 31 May 2021

During an inspection looking at part of the service

We carried out a desktop follow up inspection at Rushey Mead Health Centre on 19th, 27th and 31st May 2021 and focussed on the breaches of regulations following an inspection on 24th and 30th October 2019 under the following key question and population group.

  • Safe
  • Working Age People.

The practice was inspected on 24th and 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.

The key questions of 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 Rushey Mead 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 19 – Fit and proper persons employed.

This inspection focused on aspects relating to recruitment, staff immunisation records and cytology screening

At the previous inspection we also recommended that the provider should;

review the processes for equipment cleaning records, the chaperoning of patients, the 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:

  • We found that most of the concerns had been addressed but the provider needed to ensure that health and safety issues identified were followed up and acted on in a timely manner.

  • 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.

  • Equipment cleaning records were now in place to enable staff to demonstrate that cleaning procedures have been carried out as per the practice protocol.

During the last inspection we said that the provider shoud continue to monitor and improve patient telephone access to appointments and satisfaction with the type of appointments offered. During this inspection we found:

  • The practice was in the process of implementing a new appointment system. The new system provided patients with extra and improved access to appointments.

  • Improvements were also made to staffing to provide continuity for patients. This included the appointment of salaried GPs.

  • The management team had the ability to manage queues and assign workforce in accordance with peak times. Quarterly audits were carried out.

The rating for the population group of Families, Children and Young People is rated as Good because:-

  • Data demonstrated that improvements had been made in all five childhood immunisation uptake indicators since the last inspection.

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%.
  • Improvements had been made so that people were able to access care and treatment in a timely way.

Whilst we found no breaches of regulations, the provider should:

  • Improve the records kept for health and safety and ensure actions identified are addressed.
  • Promote and drive the uptake of cervical screening programmes with patients registered at the practice.

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

24 & 30 October 2019

During a routine inspection

We carried out a new registration announced comprehensive inspection at Rushey Mead Health Centre on 24 October 2019 and 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 practice could not demonstrate that its staff recruitment procedures were consistently followed as there was an absence of 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.
  • The practice chaperone procedure did not provide staff with appropriate guidance on where they should position themselves when carrying out the role a chaperone.
  • Equipment cleaning records were completed. However, the information requested in the log did not allow for confirmation that the cleaning process had been carried out correctly.

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 and cytology screening were below the national minimum uptake and the national targets.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs.
  • Although the level of satisfaction had improved at the practice the national GP survey identified that patients were not satisfied with access to appointments at the practice.
  • 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 equipment cleaning records to enable staff to demonstrate that cleaning procedures have been carried out correctly.
  • Continue to monitor and improve the uptake of childhood immunisations.
  • Continue to monitor and improve patient telephone access to appointments and satisfaction with the type of appointments offered.
  • Review the chaperone procedure so that staff have clear guidance on where they should position themselves when carrying out the role of a chaperone.

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