The Care Quality Commission
  • Doctor
  • GP practice

Cossington Park Surgery

Overall: Requires improvement read more about inspection ratings

52 Brandon Street, Leicester, Leicestershire, LE4 6AW (0116) 268 970

Provided and run by:
WB Medical Group

Important: The provider of this service changed. See old profile

All Inspections

24 January 2024

During a routine inspection

We carried out an announced focused inspection at Cossington Park Surgery on 24 January 2024. This was to follow up on a Section 29 warning notice we issued at the previous inspection in September 2023 in relation to a breach of regulation 17 good governance.

In September 2023, the practice was rated as requires improvement overall and for all key questions. This inspection took place on the 24 January 2024 to review compliance with the warning notice which needed to be met by 10 October 2023, but the inspection was not rated. The ratings from September 2023 therefore still apply and will be reviewed via a further inspection in due course.

The ratings from September 2023 still apply and the service remains rated as requires improvement overall and for all key questions:

Safe - requires improvement

Effective - requires improvement

Caring - requires improvement

Responsive - requires improvement

Well-led - requires improvement

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Cossington Park Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up on a breach of regulation from a previous inspection. The report only covers our findings in relation to concerns raised in the warning notice and will not change the ratings.

At the inspection, we found that most of the requirements of the warning notice had been met. However, there was a continued breach of regulation 17 in relation to summarised records. The level of this breach has been reduced to a requirement notice.

How we carried out the inspection

  • 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.

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 could not demonstrate that all patient records were summarised appropriately and there was a lack of evidence around processes for ensuring the risk to patients were mitigated.
  • Medicines were being prescribed and reviewed appropriately.
  • Processes had been implemented to ensure monitoring of high risk medicines were in place.
  • The system for receiving and acting on safety alerts had improved.
  • There was no evidence of missed diagnoses within the practice.
  • Patients with long term conditions were being reviewed in a timely manner.

We found a continued breach of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We also found that the provider should:

  • Implement a process for patients who do not comply with monitoring requirements to ensure they continue to receive safe and effective treatment.

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 Health Care

25 July 2023

During a routine inspection

We carried out an announced comprehensive at Cossington Park Surgery on 25 July 2023. Overall, the practice is rated as requires improvement.

Safe – requires improvement

Effective - requires improvement.

Caring – requires improvement.

Responsive – requires improvement.

Well-led – requires improvement.

Following our previous inspection in February 2019 the practice was rated as good overall and for all the key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Cossington Park Surgery on our website at www.cqc.org.uk

Why we carried out this inspection.

We carried out this inspection to follow up on concerns that were reported to us. We inspected all key questions.

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.

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 provide care in a way that kept patients safe and protected them from avoidable harm.
  • Systems around recalling patients for monitoring of medicines and long-term conditions were not always effective.
  • Oversight of test results needed improving to ensure patients were diagnosed and followed up in a timely manner.
  • Patients did not always receive effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • Governance structures within the practice needed to be strengthened to outline responsibilities and systems in place.

We found one breach of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Along with the breach of regulation found, the provider should:

  • Improve uptake rates for cervical screening.
  • Take action to proactively identify and support carers within the practice.
  • Improve record keeping for areas such as complaints, significant events and meeting minutes.

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 Health Care

4 February 2019

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Brandon Street Surgery on 13 January 2017. The overall rating for the practice was good with requires improvement for providing safe services.

From the inspection in January 2017 the practice was told they must:

  • Review processes for reporting, recording, acting on and monitoring significant events, incidents and near misses. Ensure actions agreed to ensure lessons learnt following discussion of a significant event are documented with timely review dates. Ensure complete records are kept of all completed significant event report forms received including details of actions taken as a result.

In addition, the practice was told they should:

  • Review processes in place in relation to clinical audits to ensure full cycle audits are carried out to improve patient outcomes.
  • Review system of appraisals to ensure all members of staff receive an appraisal at least annually.
  • Review complaints processes to keep a record of informal complaints received and ensure a system is in place to enable the practice to monitor trends.
  • Review methods of communication and meeting structures to ensure all practice staff clinical and non-clinical are provided with the opportunity to be involved in discussions about the practice.

The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Brandon Street Surgery on our website at .

This inspection was an announced focused inspection carried out on 4 February 2019 to confirm that the practice had made the recommended improvements that we identified in our previous inspection on 13 January 2017. This report covers our findings in relation to those improvements made since our last inspection.

Our judgement of the quality of care at this service is based 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.

The practice is rated as good overall and good for all the population groups.

At this inspection we found:

  • The practice had implemented a system to ensure that significant events were managed safely and that learning from those events was shared across the practice.
  • We saw evidence that when a significant event took place, it was appropriately recorded and acted upon.
  • Risks to patients were now being safely managed and mitigated.
  • We saw evidence that full cycle audits had been completed since our last inspection. Further audits had been completed and we saw evidence that future audits were planned.
  • A system had been implemented to ensure staff received regular appraisals and we saw evidence that appraisals had been carried out with staff since our last inspection. These appraisals covered staff training needs and any performance issues.
  • Complaints received in written or verbal form were now being captured by staff in order to effectively monitor these, share learning across the practice and identify any trends and themes.
  • A schedule of meetings now took place at the practice which included monthly clinical meetings, monthly nurse clinical meetings, all staff meetings and safeguarding meetings with health visiting teams when they were available. We saw meeting from these minutes and saw that significant events and complaints were discussed.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

13 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Brandon Street Surgery on 13 January 2017. Overall the practice is rated as good.

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

  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • We found that the system for reporting and recording significant events was inconsistent and required review. We were unable to see evidence of discussion of actions taken or lessons learnt discussed or shared with the practice team. The practice did not document discussions held regarding near misses.
  • Information about services and how to complain was available for patients. However, the practice did not keep a record of informal complaints received to enable the practice to identify any trends in complaints.
  • Risks to patients were assessed and well managed.
  • The practice had made significant improvement to Qof performance however, patient outcomes were hard to identify as little or no reference was made to audits or quality improvement with the exception of medicines management audits that had been carried out.
  • Childhood immunisations were carried out in line with the national childhood vaccination programme. Uptake rates for the vaccines given to five year olds were higher than CCG/national averages.
  • The practice had a proactive patient participation group and had sought feedback from patients.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • 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.
  • The provider was aware of the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Review processes for reporting, recording, acting on and monitoring significant events, incidents and near misses. Ensure actions agreed to ensure lessons learnt following discussion of a significant event are documented with timely review dates. Ensure complete records are kept of all completed significant event report forms received including details of actions taken as a result.

The areas where the provider should make improvement are:

  • Review processes in place in relation to clinical audits to ensure full cycle audits are carried out to improve patient outcomes.
  • Review system of appraisals to ensure all members of staff receive an appraisal at least annually.
  • Review complaints processes to keep a record of informal complaints received and ensure a system is in place to enable the practice to monitor trends.
  • Review methods of communication and meeting structures to ensure all practice staff clinical and non-clinical are provided with the opportunity to be involved in discussions about the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice