• Doctor
  • GP practice

Horizon Healthcare

Overall: Good read more about inspection ratings

The Charnwood Surgery, 5 Burton Road, Derby, Derbyshire, DE1 1TH (01332) 737777

Provided and run by:
Horizon Healthcare

All Inspections

28 November 2023

During a routine inspection

We carried out an announced comprehensive at Horizon Healthcare on 24 and 28 November 2023. Overall, the practice is rated as good. Due to assurances we received from our review of information, we carried forward the rating of good from our previous inspection in May 2016 for the key question caring. We rated the practice as good for providing safe, effective and well-led services and requires improvement for providing responsive services.

Following our previous inspection on 26 May 2016, the practice was rated good overall and for all key questions.

The full report for the previous inspection can be found by selecting the ‘all reports’ link for Horizon Healthcare on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

  • We inspected the key questions safe, effective, responsive and well-led.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing remote clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patients’ records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A site visit.
  • Staff feedback forms.
  • Speaking with a member of the Patient Participation Group.
  • Speaking with representatives of 3 care homes where the practice provided care and treatment.

Our findings

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 rated the practice as good for providing safe, effective and well-led services because:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • The practice learned and made improvements when things went wrong.
  • Patients received effective care and treatment that met their needs.
  • The indicators for childhood immunisation and cervical screening uptake rates were below national targets. Initiatives had been put in place to address this.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

However, we rated the practice as requires improvement for providing responsive services because:

  • The results of the National GP Patient Survey showed that patient satisfaction with telephone access to appointments and overall experience of making an appointment was low. We recognise the pressure that practices are currently working under and the efforts staff are making to maintain levels of access for their patients. At the same time, our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. Although we saw the practice was attempting to improve access, this was not yet reflected in the GP patient survey data. Therefore, the rating is requires improvement, as ratings depend on evidence of impact and must reflect the lived experience that people were reporting at the time of inspection.

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

  • Take steps to obtain proof of immunity to hepatitis B for staff who had received vaccination to confirm they had acquired immunity.
  • Clearly document when fire safety drills have taken place and the learning from them.
  • Review their systems for acting on safety alerts such as Medicines and Healthcare Products Regulatory Agency (MHRA) alerts.
  • Embed into practice formal systems to audit the prescribing of non-medical prescribers and support their competence through formal clinical supervision. Embed into practice revised systems for tracking prescription stationery throughout the practice.
  • Continue to act upon the immunisation and cervical screening uptake rates and embed into practice the role of the cancer co-ordinator.
  • Continue to monitor patient satisfaction with access to appointments and act on the feedback provided.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

26 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Charnwood Surgery on 26 May 2016. Overall the practice is rated as good.

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

  • The practice demonstrated an open and transparent approach to safety. There were systems in place to enable staff to report and record significant events. Learning from significant events was shared with relevant staff.
  • Risks to patients were assessed and well managed. There were arrangements in place to review risks on an ongoing basis to ensure patients and staff were kept safe. However, the practice needed to ensure arrangements were in place to undertake regular fire drills.
  • Staff delivered care and treatment in line with evidence based guidance and local guidelines. Training had been provided for staff to ensure they had the skills and knowledge required to deliver effective care and treatment for patients.
  • Regular clinical audits were undertaken within the practice to drive improvement.
  • Feedback from patients was that they were treated with kindness, dignity and respect and were involved in decisions about their care.
  • 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.
  • Patients said they generally found it easy to make an urgent appointment but that they sometimes had to wait to see a named GP.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. Adjustments had been made to the premises to ensure these were suitable for patients with a disability.
  • There was a clear leadership structure which all staff were aware of. Staff told us they felt supported by the partners and 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.

There were some areas where the provider should make improvements:

  • Ensure that there are robust systems in place to record action taken in response to medicines and patient safety alerts received.
  • Ensure arrangements are in place to undertake regular fire drills within the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice