The Care Quality Commission
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  • GP practice

Archived: Melbourne Road Health Centre - R Kapur

Overall: Requires improvement read more about inspection ratings

47 Melbourne Road, Leicester, Leicestershire, LE2 0GT (0116) 255 9869

Provided and run by:
Dr Kapur & Partners

All Inspections

21 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Melbourne Road Health Centre – R Kapur on 21 March 2016. Overall the practice is rated as requires improvement

Our key findings across all the areas we inspected were as follows:

  • Data from the Quality and Outcomes Framework showed patient outcomes were above average for the locality and the national average.

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Not all risks to patients were assessed and well managed. The practice did not have a carpet cleaning schedule in place. Not all areas of the practice were cleaned in line with the practice cleaning schedule and guidelines.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had a number of policies and procedures to govern activity.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Ensure appropriate systems and processes are in place relating to infection control in line with national guidance, ensuring consulting and treatment rooms are cleaned as per practice cleaning schedule and guidelines and implementation of carpet cleaning schedules.
  • Ensure a suitable fire detection and alarm system is installed to ensure compliance with the action plan served by Leicestershire Fire Service (LFS).  Ensure fire risk assessment is effective and all hazards are identified.
  • Ensure the property is appropriately maintained and remedial repairs carried out to ensure the health and safety of staff, patients and visitors.

  • Ensure procedures for monitoring and recording of water temperatures are in place, in line with the practice Legionella risk assessment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

8 July 2014

During a routine inspection

The practice provides GP services to approximately 3000 patients in the centre of Leicester city from Melbourne Road Health Centre, Melbourne Road, Leicester. The premises is an older three storey building. The practice provides a range of primary medical services which includes family planning and minor surgery.

This was an announced inspection, which focused on whether the care and treatment of patients was: safe, effective, caring, responsive and well led. We spoke with six patients and two representatives of the patient reference group (PPG). The PPG is a group of patients who highlight patient concerns and needs and work with the practice to drive improvement within the service. We reviewed written and verbal feedback from patients and observed how staff interacted with patients. The majority of the feedback about patients’ care and treatment was positive.

We reviewed Information from Leicester City clinical commission group (CCG) and Public Health England.

We found the practice understood the local patient population and provided flexible and responsive services to meet their needs. Patients told us they found the service accessible and were involved in making decisions about their care and treatment.

Staff we spoke with told us they were well supported by the GPs and practice manager and that they found them open and approachable. We saw that there were systems in place to safeguard vulnerable adults and children from abuse.

We found the practice responded to the needs of older people, people with long term conditions, mothers, babies, children and young people, the working age population, people in vulnerable circumstances and people who were experiencing poor mental health.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.