Background to this inspection
Updated
1 November 2023
South Leicestershire Medical Group is located in Leicester at:
Kibworth Medical Centre (main site)
Smeeton Road
Kibworth Beauchamp
Leicester
Leicestershire
LE8 0LG
The practice has branch surgeries located at:
• Fleckney Medical Centre, High Street, Fleckney, Leicester. LE8 8AJ
• Great Glen Surgery, 24a Main Street, Great Glen, Leicester. LE8 9GG
• Old School Surgery, 2a Station Street, Kibworth, Leicester. LE8 0LN
• Market Harborough, Torch Way, Market Harborough, Leicestershire. LE16 9HL
• Fleckney Duck Pond Surgery, 6a High Street, Fleckney, Leicester. LE8 8AJ
As part of our inspection we visited Kibworth Medical Centre.
There is a dispensary at Kibworth Medical Centre which was inspected as part of this inspection.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, surgical procedures, family planning, and treatment of disease, disorder or injury and surgical procedures. These are delivered from all sites to a patient population of about 24,660.
The practice is situated within the Leicester, Leicestershire and Rutland integrated care system area (ICS) and delivers General Medical Services (GMS). This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices as part of the Cross Counties Primary Care Network (PCN). It is one of three GP practices within the PCN.
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 93.6% White, 4.6% Asian, and 1.8% Other.
The age distribution of the practice population closely mirrors the local averages. However, there are lower numbers of patients in the age category of 20-45, and higher numbers of older people in comparison to national averages.
There is a team of 7 GP partners and 8 salaried GPs who provide cover across the practice’s sites. The practice has a team of 4 advance nurse practitioners and 6 nurses supported by 7 health care assistances. The practice has also had paramedics, mental health nurses, physiotherapists, pharmacists and a dispensary team.The GPs are supported at the practice by a team of reception/administration staff. The practice manager and assistant practice manager are based at the main location to provide managerial oversight.
The practice opens Monday to Friday from 8am until 6.30pm. Opening times vary across the six sites.
Extended access is currently provided locally with morning appointments and late evening appointments. At the weekend this is covered by Cross Counties Primary Care Network. Out of hours services are provided by Derbyshire Healthcare United.
Updated
1 November 2023
We carried out an announced focused inspection at South Leicestershire Medical Group on 20 June 2023. Overall, the practice is rated as requires improvement.
Safe - Requires improvement
Effective - Requires improvement
Caring – Not inspected, rating of good carried forward from previous inspection
Responsive - Requires improvement
Well-led - Requires improvement
Following our previous inspection on 28 April 2022 the practice was rated requires improvement overall and for all key questions but rated good in caring.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for South Leicestershire Medical Group on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection to follow up on concerns and breaches of regulation from a previous inspection in line with our inspection priorities.
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 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 short site visit.
- Staff questionnaires.
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 code safeguarding records effectively or deal with safeguarding tasks in a timely manner.
- Services within the dispensary were not always being delivered in line with regulations.
- Medicine reviews were not always effective or completed in a timely manner.
- Patients were not always able to access care and treatment in a timely way.
- Practice leaders were not always aware of poor performance within some areas of the practice.
- The practice did not operate effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
We found a breach of regulation. The provider must:
- 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 :
- Continue to identify, contact and assess patients who are eligible for NHS health checks.
- Continue to review and improve the system and process to gain feedback from patients in relation to access.
- Document discussions had with patients in medical records in respect of risks associated from safety alerts.
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