The Care Quality Commission
  • Doctor
  • GP practice

Archived: Asquith Surgery

Overall: Good read more about inspection ratings

693 Welford Road, Leicester, Leicestershire, LE2 6FQ (0116) 323 2000

Provided and run by:
Spirit Healthcare Ltd

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

All Inspections

19th and 24th May 2021

During an inspection looking at part of the service

We carried out a desktop follow up inspection at Asquith Surgery on 19h May 2021 and focused on the breaches of regulations following an inspection on 21st and 30 October 2019 under the following key question and population group.

  • Safe

The practice was inspected on 21st and 30th October 2019 and was rated Good overall with a rating of Requires Improvement in the Safe key question. Effective, Caring, Responsive, Well-led and the population groups of Older People, People with Long Term Conditions, Families, Children and Young People, Working Age People(including those recently retired and students), 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 Asquith Surgery 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 staff immunisation records, patient group directives and recruitment.

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 was Good overall, and rated as Good for Safe services because:

  • A system was now in place for staff recruitment and retention
  • Records were now kept in regard to staff immunisations
  • Improvements had been made to the management of Patient Group Directives to ensure they were signed before they were approved by the lead clinician.

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

21 & 30 October 2019

During a routine inspection

We carried out a new registration announced comprehensive inspection at Asquith Surgery on 21 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 all population groups.

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.
  • PGDs were approved and signed prior to the date they were signed by the practice nurses.

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 effective care and treatment that met their needs.
  • 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. 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.

(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