The Care Quality Commission
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Archived: Heatherbrook Surgery - RP Archer and CK Archer Also known as Heatherbrook Surgery

Overall: Good read more about inspection ratings

Heatherbrook Surgery, 242 Astill Lodge Road, Leicester, Leicestershire, LE4 1EF (0116) 235 6324

Provided and run by:
Heatherbrook Surgery - RP Archer and CK Archer

All Inspections

15 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Heatherbrook Surgery (RK Archer and CK Archer) on 15 July 2015. Overall the practice is rated as good for providing safe, effective, caring, responsive and well-lead services.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and generally well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • 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.

However there were areas where the provider should make improvements. The provider should:

  • undertake complete two-cycle audits to ensure any learning is reviewed and monitored.
  • ensure staff who act as chaperones are DBS checked or that the role is risk assessed.
  • review its infection control policy and ensure people are kept safe from the risk of legionella.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

18 July 2014

During a routine inspection

Heatherbrook Surgery is a general practice serving approximately 3,300 patients in the north-west area of Leicester. The practice serves the local community and provides a range of services for the residents in the area.

We inspected the practice on 18 July 2014 and spoke with the GPs, the practice manager, practice nurse, other staff and patients. We looked at policies, systems and procedures to determine if the practice was safe, effective, caring, responsive to people’s needs and well-led. We also received information and feedback from the Leicestershire Clinical Commissioning Group (CCG), and reviewed feedback from other sources, such as NHS Choices.

Overall, the practice was effectively meeting the needs of patients . We found that the practice had some areas in which improvements were required. Arrangements related to the management of emergency medicines and risk needed to be more robust in order to ensure patient safety. Improvements were also needed in relation to an awareness of the Mental Capacity Act 2005 and consent to treatment..

We found the practice was caring. The staff we spoke with demonstrated a caring culture towards patients. The patients we spoke with told us they were pleased with the service. People told us the GPs were very kind and considerate.

The practice was responsive and provided services to meet the different needs of the patients at the practice, such as maternity, antenatal and postnatal care, smoking cessation support and immunisations.

The practice was assessing and monitoring the quality of its service provision. It did not have formal systems in place to monitor and improve the quality of services. Some clinical reviews and audits had improved delivery for patients, but routine and regular checks and audits were not always in place.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.