The Care Quality Commission
  • Doctor
  • GP practice

Mickleover Surgery

Overall: Good read more about inspection ratings

10 Cavendish Way, Mickleover, Derby, Derbyshire, DE3 9BJ (01332) 519160

Provided and run by:
Mickleover Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Mickleover Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Mickleover Surgery, you can give feedback on this service.

25 Nov 2019

During an inspection looking at part of the service

We carried out an unannounced focussed inspection at Mickleover Surgery on 25 November 2019 due to receiving some concerning information which had been raised about the practice, however our inspection did not evidence the information was correct.

The practice was last inspected in 2017 and the full report can be found on the website .

At this inspection we did not find any breaches or concerns around patient safety. Our key findings at this inspection were:

  • Systems were in place to ensure patients receiving high risk medicines were having the appropriate monitoring completed in a timely manner.
  • Patients received appropriate reviews for their long term conditions with follow ups arranged appropriately.
  • Test results and tasks on the clinical system were acted on appropriately and in a timely manner.
  • There were systems to ensure infection control was audited however there were some areas which could have been reviewed following the previous audit to review progress on the issues highlighted.

Details of our findings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

27 January 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Mickleover Surgery on 17 November 2015. The overall rating for the practice was good . Following the inspection t he practice sent us an action plan to address a requirement that the provider was not meeting.

The inspection report dated 17 November 2015 can be found by selecting the ‘all reports’ link for Mickleover Surgery on our website at www.cqc.org.uk. 

We carried out a follow up focused inspection of Mickleover Surgery on 27 January 2017, to check that the practice had completed their plan to meet the legal requirement we identified at our last inspection. This report covers our findings in relation to the requirement and improvements made.

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

  • The practice had completed their action plan and was now meeting the  legal requirement . ​
  • ​ Effective governance systems were in place to assess, oversee and improve the quality and safety of the services provided.
  • The systems for identifying, recording and learning from  safety incidents and significant events had been strengthened, to ensure  appropriate improvements had taken place .​
  • The clinical audit programme had been further developed to support ongoing quality improvement and effective care, through completed audit cycles. The practice had implemented an annual audit programme, which included re-audit dates and when these had been completed.
  • The practice had adopted a more proactive approach in planning, recording and monitoring staff training. A clear annual training plan had been implemented, which provided an up to date record and overview of training that all staff had completed, or were due to attend. 
  • Opportunities for all staff to meet as a full team to attend essential training, aid communication, and share learning had increased. Full team training events and meetings were scheduled to take place four times each year.
  • To support protected learning time and enable all staff to attend full team events, the Clinical Commissioning Group were funding the future cost of Derbyshire Health United provider covering the practice whilst it closed . The practice previously funded this.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

17 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mickleover Surgery on 17 November 2015. Overall the practice is rated as good. Our key findings across the areas we inspected were as follows:

  • Feedback from patients was consistently positive about the care and treatment they received, and the way staff treated them. Patients were treated with kindness, dignity and respect.

  • Patients were able to access care and treatment when they needed it, and most people could access appointments and services in a way, and at a time that suited them.

  • Staff worked in partnership with other services to ensure that patients’ needs were met.

  • Overall, systems were in place to keep patients safe, although the systems for identifying and managing safety incidents and significant events required strengthening.

  • The practice had appropriate facilities and was well equipped to treat patients and meet their needs.

  • There was an open, positive and supportive culture.

  • Staff were actively supported to develop their knowledge and acquire new skills to provide high quality care.

  • The practice was generally well-led. The leadership and culture promoted the delivery of high-quality, compassionate care. However, aspects of the governance systems required strengthening to further improve the services provided.

  • The practice actively sought feedback from patients, which it acted on to improve the services.

Importantly, the provider must:

  • Ensure effective systems are in place to assess, monitor and further improve the quality and safety of the services provided.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice