Background to this inspection
Updated
24 June 2021
Spirit Healthcare Ltd. has been the registered provider for Rushey Mead Health Centre since October 2017.
Rushey Mead Health Centre is located at 8 Lockerbie Walk, Leicester. LE4 7ZX. The premises are a purpose built health centre. Rushey Mead Health Centre is one of four GP practices run by Spirit Healthcare Ltd.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services ,family planning, treatment of disease, and disorder or injury and surgical procedures.
The practice is part of the NHS Leicester City CCG and delivers Alternative Provider Medical Services (APMS) to a patient population of 4,655. This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices called City Care Alliance Primary Care Network
Information published by Public Health England, rates the level of deprivation within the practice population group as 2602 out of a maximum of 6,900, indicating they are in a slightly more deprived area. Deprivation rankings area at England level, the lower the number the more deprived the practice or CCG is relative to others.
The National General Practice Profile states that 29% of the practice population is from a white
background and 64% from an Asian background, 3% black and 4% from a mixed or non-white background.
There is a team of one lead GP,three salaried GPs, one practice nurse and one assistant practitioner, who work at the practice. The clinicians are supported by a practice manager alongside reception staff. Spirit Healthcare have a centralised administration team who provide back office support to the three locations based in Leicester.
The practice is open Monday to Friday 8am to 6.30pm and patients were being asked to call the practice to make an appointment.
Due to the enhanced infection prevention and control measures put in place since the 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 an appointment.
The practice has opted out of the requirement to provide GP consultations when the surgery is closed. Out- of-hours services are provided by Derbyshire Health United, which is accessed via the NHS 111 service.
Updated
24 June 2021
We carried out a desktop follow up inspection at Rushey Mead Health Centre on 19th, 27th and 31st May 2021 and focussed on the breaches of regulations following an inspection on 24th and 30th October 2019 under the following key question and population group.
The practice was inspected on 24th and 30th October 2019 and was rated Good overall with a rating of Requires Improvement in the Safe key question and the population group of Working Age People.
The key questions of Effective, Caring, Responsive, Well-led and the population groups of Older People, People with Long Term Conditions, Families, Children and Young People, People whose circumstances may make them vulnerable and People experiencing poor mental health (including people with dementia) were rated as Good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Rushey Mead Health Centre on our website at www.cqc.org.uk
Why we carried out this review
This inspection was a review of information without undertaking a site visit inspection to follow up on breaches of Regulations 12 – Safe Care and Treatment and Regulation 19 – Fit and proper persons employed.
This inspection focused on aspects relating to recruitment, staff immunisation records and cytology screening
At the previous inspection we also recommended that the provider should;
review the processes for equipment cleaning records, the chaperoning of patients, the uptake of childhood immunisations and patient experience in particular telephone and appointment access.
How we carried out the inspection/review
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 reviews differently.
This review was carried out remotely and therefore we did not spend any time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included: -
- Requesting evidence from the provider
- Clarification of evidence with the provider
Our findings
We based our judgement of the quality of care at this service on a combination of:
- what we found when we reviewed the evidence sent by the provider
- information from our ongoing monitoring of data about services and information from the provider, patients, the public and other organisations.
At this inspection the practice remained Good overall, the breaches of regulation were met but the practice remains Requires Improvement for Safe services because:
- We found that most of the concerns had been addressed but the provider needed to ensure that health and safety issues identified were followed up and acted on in a timely manner.
- A system was now in place for staff recruitment and retention.
- Records were now kept in regard to staff immunisations.
- Chaperone policy was in place which gave guidance to staff.
- Equipment cleaning records were now in place to enable staff to demonstrate that cleaning procedures have been carried out as per the practice protocol.
During the last inspection we said that the provider shoud continue to monitor and improve patient telephone access to appointments and satisfaction with the type of appointments offered. During this inspection we found:
- The practice was in the process of implementing a new appointment system. The new system provided patients with extra and improved access to appointments.
- Improvements were also made to staffing to provide continuity for patients. This included the appointment of salaried GPs.
- The management team had the ability to manage queues and assign workforce in accordance with peak times. Quarterly audits were carried out.
The rating for the population group of Families, Children and Young People is rated as Good because:-
- Data demonstrated that improvements had been made in all five childhood immunisation uptake indicators since the last inspection.
The rating for population group of Working Age People (including those recently retired and students) remains as Requires Improvement because:
- The percentage of women eligible for cervical cancer screening at a given point in time who were screened adequately within a specified period was still below 70% and below the national target of 80%.
- Improvements had been made so that people were able to access care and treatment in a timely way.
Whilst we found no breaches of regulations, the provider should:
- Improve the records kept for health and safety and ensure actions identified are addressed.
- Promote and drive the uptake of cervical screening programmes with patients registered at the practice.
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