Severn Surgery

Updated 2 November 2023

Severn Surgery is located in the town of Oadby in Leicestershire at:

159 Uplands Road

Oadby

Leicester

LE2 4NW

Severn Surgery became the new name of the registered provider of this service from April 2023. The partnership had changed in September 2022.

The provider is registered with CQC to deliver the Regulated Activities, diagnostic and screening procedures, family planning, maternity and midwifery services, and treatment of disease, disorder or injury.

Severn Surgery is situated within the NHS Leicester, Leicestershire and Rutland Integrated Care Board (LLR ICB) and delivers General Medical Services (GMS) to a patient population of approximately 11,970. This is part of a contract held with NHS England. An Integrated Care Board (ICB) is a statutory organisation bringing the NHS together locally to improve population health and establish shared strategic priorities within the NHS.

The practice is part of a wider network of GP practices as a member of Watermead Primary Care Network, based in Leicester.

Information published by Public Health England shows that deprivation within the practice population group is in the highest decile (10 of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 48% Asian, 46% White, 1% Black, 2% Mixed, and 3% Other.

The age distribution of the practice population mostly mirrors the local and national averages.

The practice is registered with the CQC as a partnership consisting of two GPs and one advanced clinical practitioner, who is also the CQC Registered Manager. The practice has a team of six long-term regular GP locums. The clinical team also includes a pharmacist, an advanced nurse practitioner, two practice nurses, a pharmacy technician and a healthcare assistant. There is also a physician associate and a physiotherapist who work within the practice. The clinical team are supported at the practice by a practice manager, three medical secretaries and twelve patient services advisors.

The practice opens Monday to Friday from 8.00am to 6.30pm. The practice is closed at weekends and on bank holidays.

Extended access is provided locally where late evening and weekend appointments are available. Out of hours services are provided by Derbyshire Health United via the 111 service.

Updated 2 November 2023

We carried out an announced comprehensive inspection at Severn Surgery on 12 May 2023 to review their progress since taking over the contract at the practice. Overall, the practice is rated as inadequate.

Safe - Inadequate

Effective - Inadequate.

Caring - Good

Responsive - Good

Well-led - Requires improvement.

Following our previous inspection on 22 June 2022, the practice was rated as inadequate overall. The partnership of the practice changed in September 2022 and under our continuing regulatory history policy, the rating of inadequate was inherited. At this inspection, which is the first inspection of the new partnership, we found some improvements had been made to address areas of concern which were found at the previous inspection under the previous partnership, however some areas needed to continue to be embedded in order to improve.

The full reports for previous inspections can be found on our website at www.cqc.org.uk.

Why we carried out this inspection.

We carried out this inspection to follow up on previous concerns and the practice being in special measures. We reviewed all key questions as part of the inspection.

How we carried out the inspection.

• Undertaking a site visit.
• Conducting staff interviews remotely and on site.
• Completing 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 patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider to be submitted prior to the inspection and reviewing evidence during the site visit.

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 found that:

• The practice did not always provide care in a way that kept patients safe and protected from harm.
• Patients taking regular medicines were not always monitored in line with national guidance.
• Safety alerts were not always being received and acted upon, which put patients at risk.
• The practice did not always identify patients with long term conditions.
• Not all patients received effective care and treatment that met their needs. Patients with long term conditions were not always being reviewed effectively.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way. On the day appointments were regularly available.
• A new management and leadership structure had been implemented to support staff through the transition of services.
• Systems and processes needed to be strengthened to support good governance in accordance with the fundamental standards of care.

We found two breaches of regulations. The provider must:

• Ensure care and treatment are provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, there were areas the provider could improve and should:

• Ensure Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) documentation is complete and full assessments have been documented.
• Continue to complete reviews for patients with learning disabilities.
• Continue to increase uptake rates for childhood immunisations and cancer screening.

This practice was placed in special measures following our previous inspection on 22 June 2022 when different partners were at the practice. The practice will be kept under review and a comprehensive inspection will be carried out at the end of the special measures period. If necessary we shall take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling the registration or to varying the terms of the registration if the practice does not improve.

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 Hospitals and Interim Chief Inspector of Primary Medical Services