The Care Quality Commission
  • Doctor
  • GP practice

The Surgery@Aylestone

Overall: Good read more about inspection ratings

672 Aylestone Road, Leicester, Leicestershire, LE2 8PR

Provided and run by:
The Surgery@Aylestone

All Inspections

28 September 2023

During a routine inspection

We carried out an announced comprehensive inspection at The Surgery@Aylestone on 28th September 2023. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive – Requires improvement

Well-led - Good

We previously inspected the practice in October 2019 and rated the practice as Good overall. We subsequently carried out an inspection in February and March 2022 to in response to information of concern received about the quality and safety of the service highlighting a lack of effective leadership and clinical oversight. During this inspection the overall rating was Requires Improvement.

As a follow up to this, we carried out this inspection on the 28th September 2023 and have rated the practice as Good overall. After the clinical searches and on-site inspection, we found there was safe patient care and governance oversight had been reviewed and now monitored the quality and effectiveness of the service through embedded systems and processes.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Surgery@Aylestone on our website at www.cqc.org.uk

Why we carried out this inspection.

We carried out this inspection in response to concerns shared with the CQC. It was a comprehensive inspection which looked at:

All 5 key questions: safe, effective, caring, 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 and in person.
  • 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.
  • A site visit on 28th September 2023.

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.
  • Information from the provider, patients, the public and other organisations.

We have rated the practice as Good overall.

We found that:

  • Systems and processes were embedded in the way care was delivered.
  • Our searches showed the safe use of medicines and regular monitoring of patients to optimise treatment.
  • There was an effective system in place to manage long term conditions, Dedicated staff oversee registers of patients with long term conditions, conducted health and medicine reviews.
  • The practice had a programme of learning and development to provide staff with the skills, knowledge, and experience to carry out their roles and we saw evidence of effective overall monitoring of patients with long term conditions.
  • The practice had put systems in place to recall patients for immunisation and cancer screening, utilising community teams when appropriate.
  • Staff we spoke to told us they felt supported and were able to approach leaders whenever the need presented. They were positive about improving patient care. The leadership team were keen to deliver a well-led service.
  • Systems and processes were embedded in the day-to-day operation of the practice.

The practice is rated as requires improvement for providing responsive services following this inspection. This is because the national GP survey results are lower than local and national averages, and although the practice has implemented changes there is not yet evidence to show it has improved patient experience.

The provider should:

  • Continue to improve their cervical screening and childhood immunisation uptake which was below the national target of 80% and 90% respectively.
  • Monitor the changes made for patients to access care and ensure they are improving patient satisfaction.

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

02 February 2022, 03 and 08 March 2022

During an inspection looking at part of the service

We carried out an unannounced focused inspection visit on 2 February 2022, this was followed by two further visits on 3 and 8 March 2022 at The Surgery@Aylestone. Overall, the practice is rated as Requires Improvement.

We rated each key question as follows:

Safe - Requires Improvement.

Effective - Requires Improvement.

Well-led - Requires Improvement.

The practice was inspected 31 October 2019 and rated Good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Surgery@Aylestone on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection and included a site visit. The inspection was in response to information of concern received about the quality and safety of the service highlighting a lack of effective leadership and clinical oversight.

How we carried out the inspection

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 inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short 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 have rated this practice as Requires Improvement overall

We found that:

  • The practice did not have fully effective systems in place for the appropriate and safe use of medicines, this included regular monitoring arrangements for patients on high risk medicines. The practice was taking action to improve.
  • There was an inconsistent approach to the management of patients care and treatment including those with long term conditions with a lack of effective clinical oversight. The practice was taking action to improve.
  • The practice was below national target for uptake of cervical screening.
  • The processes for managing quality and safety risks were not always supported by fully embedded assurance systems.
  • There were effective systems and processes in place for recruitment and infection prevention and control.
  • Staff were provided opportunities for training and development with access to appraisals, and clinical supervision.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.

We found two breaches of regulations. The provider must:

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

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

  • Undertake a legionella (a bacteria found in water) risk assessment, to determine potential level of risk and any mitigating action required.
  • Implement comprehensive quality assurance systems to demonstrate the competency of staff undertaking extended roles.
  • Implement effective protocols for remote or online prescribing to verify patients identity.
  • Continue to monitor and take action to improve the uptake of cervical screening.

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

31 October 2019

During a routine inspection

We carried out an announced comprehensive inspection at The Surgery@Aylestone on 31 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 found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • The practice had identified 3% of the practice list were carers. They were supported and offered health checks combined with flu vaccinations. The practice had a separate register for young carers.
  • We were told that the nurses had implemented a system which had increased uptake and success of chlamydia screening
  • 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 practice had designed, developed and improved significant event reporting ensuring that staff could easily report any significant events including near misses, staff accidents, whistleblowing and infection control concerns.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

  • Improve the identification of young carers to enable this group of patients to access the care and support they need.
  • Continue to monitor any introduction of new substances located on the premises and include in the Control of Substances Hazardous to Health Regulations (COSHH) checklist to ensure patient safety.
  • Improve levels of patient satisfaction, in particular, those in relation to access.

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

24 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Surgery@Aylestone on 24 March 2017. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • The practice’s computer system alerted GPs if a patient was also a carer. The practice had identified 72 patients as carers (2% of the practice list). Written information was available to direct carers to the various avenues of support available to them. The practice provided information to patients who may be a young carer to ensure these patients were aware of the support services available to them.
  • Information about services and how to complain was available.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • 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 the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Continue to monitor patient satisfaction results in relation to the issues highlighted in the national GP patient survey in order to improve patient satisfaction in relation to appointment access and ability to get through to the practice by phone.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice