Background to this inspection
Updated
5 February 2021
The provider of the Regulated Activities at Thurmaston Health Centre is Charnwood GP Network Ltd. It has an APMS contract and provides primary medical services to approximately 7,034 patients on the edge of the City of Leicester.
Charnwood GP Network Ltd is a partnership of GPs across Leicestershire. Charnwood GP Network Ltd was formed in April 2018 with the aim to supporting practices to deliver high quality patient care in Charnwood.
Services are provided from a single location at 573a Melton Road, Thurmaston Leicester.
The provider is registered to provide the regulated activities of;
Diagnostic and screening procedures
Maternity and midwifery services
Family Planning
Surgical procedures
Treatment of disease, disorder or injury
The registered manager is registered to manage the regulated activities of;
Diagnostic and screening procedures
Surgical procedures
Maternity and midwifery services
Family Planning
Treatment of disease, disorder or injury
The practice is led by clinical leads, who are experienced GPs who also work at other GP practices across Leicestershire.
There are five clinical leads, seven locum GPs, one advanced nurse practitioner, two nurse practitioners, two health care assistants and a full-time clinical pharmacist and a team of management, reception and administrative staff.
Deprivation levels are the highest of the four GP practices in the Watermead Primary Care Network with a high prevalence of diabetes and cardiovascular disease. The practice has an Asian population that is three times higher than the CCG average.
The practice is situated within a purpose-built modern facility which is accessible to all and has ample on-site car parking. The building is accessible to those with restricted mobility and those with mobility scooters and prams or pushchairs. It is not a dispensing practice.
The practice lies within the West Leicestershire Clinical Commissioning Group (CCG). A CCG is an organisation that brings together local GPs and experienced health professionals to take on commissioning responsibilities for local health services.
The practice reception is open between 8.30am and 6.30pm Mondays to Fridays except Thursdays when the practice closes at 1pm. Appointments are offered within these times. Initially made by telephone or video consultation but face to face appointments are available once the initial call had taken place. Pre-booked evening appointments are available Monday to Friday at other GP practices as part of a local extended access scheme. Saturday and Sunday morning appointments are also available as part of this scheme.
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
5 February 2021
The new provider, Charnwood GP Network Ltd started providing services at Thurmaston Health Centre on 11 April 2018. They inherited the ratings and special measures from the previous provider Leicester Medical Group.
We carried out a comprehensive inspection at Thurmaston Health Centre on 17 December 2020 to look at the improvements that had been made since this provider took over the contract. Due to the impact of the COVID-19 pandemic, most of the evidence was reviewed and staff interviews were carried out remotely in advance of the site visit on 1st and 2nd December 2020.
We found that the new provider had made significant improvements and addressed most of areas of concern found at the previous comprehensive inspection. The practice is rated as Requires Improvement overall and Requires Improvement for each of the key questions of Safe, Effective, Caring, Responsive and Well-led, and all the population groups.
The practice is rated as Requires Improvement for providing a safe service because: -
- Whilst the practice had most safe systems in place there needed to be further work in relation to safeguarding children and monitoring on patients on some high-risk medicines.
The practice is rated as Requires Improvement for providing an effective service and for all the population groups because: -
- The practice did not have a clear system for the recall of patients with long term conditions.
- The system in place for patients who were on the palliative care register was not effective
- Cervical screening data was below CCG and national averages and there was no process to improve uptake.
The practice is rated as Requires Improvement for providing a caring service because: -
- Although the practice had undertaken a patient survey to ascertain people’s views of the service this was limited in number and presentation of the patient population. The national patient survey reflected a less positive experience of patients at the practice.
The practice is rated as Requires Improvement for providing a responsive service because: -
- The practice did not always organise services to meet patients’ needs. Patient experience had improved but was not in line with local and national averages.
The practice is rated as Requires Improvement for providing a well-led service because: -
- Significant improvements had been made and more effective systems and processes were in place to ensure good governance in accordance with the fundamental standards of care. However further work was required on safeguarding children, monitoring of patients on a direct oral anticoagulant, recall system for patients with long term conditions, some patient records in terms of previous coding, palliative care, appraisals, formation of a patient participation group in order to provide full assurance of an effective governance system.
The areas where the provider must make improvements are:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. (Please see specific details on actions required at the end of this report).
In addition, the provider should:
- Continue to audit patient records to ensure coding and consultation entries are reviewed to ensure that safe care and treatment is provided in a safe way.
- Take action to improve the carers register to ensure support can be offered where appropriate.
- Promote and drive the uptake of cervical and cancer screening programmes with patients registered at the practice.
- Take action to review of significant event and complaints meeting minutes to ensure learning and actions are captured. discussion, learning and actions.
I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.
Details of our findings and the evidence supporting our ratings are set out in the evidence table.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care