South Street Surgery

Ilkeston Health Centre, South Street, Ilkeston, Derbyshire, DE7 5PZ (0115) 932 2933

Provided and run by:
Dr Jesbir Kaur Johal

Important: The provider of this service changed - see old profile

Inspection summaries and ratings from previous provider

On this page

Background to this inspection

Updated 19 August 2021

Dr Webb and Partners is located in Ilkeston, Derbyshire at:

Ilkeston Health Centre

South Street

Ilkeston

Derbyshire

DE7 5PZ

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 and surgical procedures.

The practice is situated within the NHS Derby and Derbyshire Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 3,545 patients. This is part of a contract held with NHS England. The practice is part of Erewash Primary Care Network, a wider network of 13 GP practices that work collaboratively to deliver primary care services.

The practice was a member of the Erewash Health Partnership (EHP), covering approximately 70,000 patients. This is a federation of 10 local GP practices who work collaboratively to ensure standardisation and efficiency, to strengthen resilience, and to derive benefits from economies of scale. Each practice is still autonomous in how they work.

Information published by Public Health England shows that deprivation within the practice population group is in the fourth lowest decile (4 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 98.2% White, 0.7% Asian, 0.8% Mixed, 0.2%% Black and 0.1% Other.

The age distribution of the practice population demonstrates a higher proportion of older patients, and lower numbers of younger patients and working age patients compared to local and national averages:

  • The percentage of older people registered with the practice is 23.8% which is above the CCG average of 20.2%, and the national average of 17.6%.
  • The percentage of working age people registered with the practice is 58% which is below the CCG average of 60.3%, and the national average of 62.2%.
  • The percentage of young people registered with the practice is 18.3% which below the CCG average of 19.5%, and the national average of 20.2%.

There is a team of two female GP partners and a male salaried GP. The practice has a team of two nurses and a health care assistant who provide nurse led clinic’s for long-term conditions. The GPs are supported at the practice by a business/practice manager and a team of reception, administration and secretarial staff.

Due to the enhanced infection prevention and control measures put in place since the Covid-19 pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.

Extended access is provided locally by Erewash Health Partnership, where late evening and weekend appointments are available. Out of hours services are provided by Derbyshire Health United.

Further information about the practice is available via their website at: www.drwebbspractice.co.uk

Overall inspection

Good

Updated 19 August 2021

We carried out an announced inspection at Dr Webb and Partners on 1 and 5 July 2021 to follow up on the findings from the last inspection on 13 January 2021. During the inspection on 13 January 2020, the practice was rated Requires Improvement overall and for the key questions safe and well-led. It was rated good for key questions effective, caring responsive.

Due to assurances we received from our review of information, we carried forward the ratings for the following key questions: caring and responsive from our last inspection in January 2020.

Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions: safe, effective and well-led.

Overall, the practice is rated as Good. Following our review on 1 and 5 July 2021, it is rated as good in safe, effective, caring, responsive and well-led, as well as in all of the population groups.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Webb and Partners on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection to follow up on:

  • Breaches in Regulation relating to Safe Care and Treatment and Good Governance
  • Two best practice recommendations:
  • Ensure staff training records are kept updated and accessible.
  • Store unused vaccines in their original packaging when returned to the practice vaccine refrigerator.

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 using video conferencing
  • 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
  • Speaking with care home staff
  • 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 Good overall and good for all population groups.

We found that:

  • The practice had actioned and put measures in place for all the improvements areas identified in the previous inspection, including the breaches in regulation.
  • Staff spoke highly about the management team and commented that leaders were visible and approachable. Staff felt supported and valued in their work.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Improvements had been made to the storage and distribution of blank prescription stationary, a risk assessment completed for the suggested emergency medicines not held in the practice, and patient group directions were in date and signed.
  • Effective processes for the safe handling of requests for repeat medicines for long-term conditions and to monitor the health of patients prescribed some high-risk medicines were in place.
  • Patients received effective care and treatment that met their needs.
  • Staff had the skills, knowledge and experience to carry out their roles. There was an overarching system in place to monitor compliance with staff training. Staff were encouraged and supported to develop their skills and move to new roles with the practice.
  • Observation of staff interactions with patients supported that patients were treated with kindness and respect. The review of patient records demonstrated that clinicians involved patients in decisions about their care.
  • 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. The majority of patients who requested to speak with a GP urgently were contacted either on the day.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • Governance arrangements had been strengthened and were working effectively. The management team had oversight of any identified risks and action had been taken to mitigate these.

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

  • Record positive significant events, which provide the opportunity to share when staff have correctly followed procedures and maintained patient safety.

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