The Surgery@Aylestone

Updated 22 January 2024

The Surgery@Aylestone is located in Leicester at:

672 Aylestone Road

Leicester

LE2 8PR

The practice is in a purpose-built health centre which consists of five consulting rooms located on the ground floor and three consulting rooms located on the first floor.

The provider is registered with CQC to deliver the regulated activities of diagnostic and screening procedures, maternity and midwifery services, family planning, treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the NHS Leicester, Leicestershire and Rutland (LLR) area and falls under the local Integrated Care Board (ICB). The practice delivers General Medical Services (GMS) to a patient population of about 4200. This is part of a contract held with NHS England.

Information published by Public Health England shows that deprivation within the practice population group is in the fourth lowest decile (four 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 is similar to other local practices in the area being 86% White, 3% ,6% Asian, 3% Black, 3% Mixed, and 0.7%.

The clinical team consists of two GP partners, a salaried GP in addition to regular locum GPs. The practice employs two nurses, a clinical pharmacist and a health care assistant. There is a team of reception/ administration staff with managerial oversight provided by the deputy manager, operational lead and reception manger.

The practice is open Monday to Friday from 8.30am to 6.30pm and provides extended opening hours between 6.30pm and 7.30pm. When the practice is closed, patients are directed to the out of hours provider.

Updated 22 January 2024

We carried out an announced comprehensive inspection at The Surgery@Aylestone on 28th September 2023. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive – Requires improvement

Well-led - Good

We previously inspected the practice in October 2019 and rated the practice as Good overall. We subsequently carried out an inspection in February and March 2022 to in response to information of concern received about the quality and safety of the service highlighting a lack of effective leadership and clinical oversight. During this inspection the overall rating was Requires Improvement.

As a follow up to this, we carried out this inspection on the 28th September 2023 and have rated the practice as Good overall. After the clinical searches and on-site inspection, we found there was safe patient care and governance oversight had been reviewed and now monitored the quality and effectiveness of the service through embedded systems and processes.

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

Why we carried out this inspection.

We carried out this inspection in response to concerns shared with the CQC. It was a comprehensive inspection which looked at:

All 5 key questions: safe, effective, caring, responsive and well-led.

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 and in person.
• 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 site visit on 28th September 2023.

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.
• Information from the provider, patients, the public and other organisations.

We have rated the practice as Good overall.

We found that:

• Systems and processes were embedded in the way care was delivered.
• Our searches showed the safe use of medicines and regular monitoring of patients to optimise treatment.
• There was an effective system in place to manage long term conditions, Dedicated staff oversee registers of patients with long term conditions, conducted health and medicine reviews.
• The practice had a programme of learning and development to provide staff with the skills, knowledge, and experience to carry out their roles and we saw evidence of effective overall monitoring of patients with long term conditions.
• The practice had put systems in place to recall patients for immunisation and cancer screening, utilising community teams when appropriate.
• Staff we spoke to told us they felt supported and were able to approach leaders whenever the need presented. They were positive about improving patient care. The leadership team were keen to deliver a well-led service.
• Systems and processes were embedded in the day-to-day operation of the practice.

The practice is rated as requires improvement for providing responsive services following this inspection. This is because the national GP survey results are lower than local and national averages, and although the practice has implemented changes there is not yet evidence to show it has improved patient experience.

The provider should:

• Continue to improve their cervical screening and childhood immunisation uptake which was below the national target of 80% and 90% respectively.
• Monitor the changes made for patients to access care and ensure they are improving patient satisfaction.

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