• Doctor
  • GP practice

Brandon Surgery Dr R Kapur Also known as Belgrave Health Centre

Overall: Good read more about inspection ratings

52 Brandon Street, Leicester, Leicestershire, LE4 6AW (0116) 295 5000

Provided and run by:
Brandon Surgery Dr R Kapur

Important: The provider of this service changed - see old profile

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Brandon Surgery Dr R Kapur on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Brandon Surgery Dr R Kapur, you can give feedback on this service.

6 July 2022

During an inspection looking at part of the service

We carried out an unannounced focused inspection of Brandon Surgery Dr R Kapur on 6 July 2022.

We did not rate the service at the inspection.

We reviewed limited aspects of three key lines of enquiry which related to concerns we received

Safe – Not rated.

Effective – Not rated.

Well Led – Not rated.

Following our previous inspection on 15 October 2021 the practice was rated Good overall and for all key questions:

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

Why we carried out this inspection

This was a focused inspection carried out following information of concern received by the CQC relating to safe care delivery at the practice.

How we carried out the inspection/review

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • A short site visit
  • Conducting staff interviews on site and by telephone

Our findings

We did not rate this practice at this inspection

We found that:

  • The provider had systems in place to ensure appropriate staff accessed information required to provide safe care.
  • The provider had appropriate systems and processes in place to manage medicines.
  • Staff had received appropriate training to support the care they delivered.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

30/09/21

During a routine inspection

We carried out an announced inspection at Brandon Surgery Dr R Kapur on 30th September 2021. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Why we carried out this inspection

This inspection was a comprehensive inspection as part of our inspection schedule where we looked at the key questions of safe, effective, caring, responsive and well-led.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • 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 have rated this practice as good overall and good for all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • Staff feedback was consistently positive about the leaders and managers within the practice.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

18 Jun to 18 Jun

During a routine inspection

We carried out an announced comprehensive inspection at Brandon Surgery Dr R Kapur, on 18 June 2019 as part of our inspection programme.

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 have rated this practice as requires improvement overall and for safe and well-led.

  • Nursing staff did not receive adequate non-patient facing time to complete training and development.
  • The significant events process was not understood by all staff. Not all staff were included in the process which limited the opportunities for learning and prevention of future incidents.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. Staff worked together and with other agencies.
  • Staff we spoke with confirmed there was an open culture, and senior staff were very approachable.
  • Recruitment checks were not carried out in accordance with regulations as a full employment history and DBS checks prior to employment were not requested.

We have rated this practice as good for effective, caring and responsive and for all population groups.

We found that:

  • Patients we spoke with and comment cards we reviewed told us staff treated patients with kindness and respect and involved them in decisions about their care. Patients were complimentary about the practice staff and especially the reception team.
  • There was an effective process for monitoring patients’ health in relation to the use of medicines including high risk medicines, with appropriate monitoring and clinical review prior to prescribing.
  • Patients’ treatment was regularly reviewed and updated. Patients with long term conditions received an annual review and patients were visited at home when necessary.
  • Patients who did not speak English or for whom English was not their first language, were called by members of the practice team who spoke the same language, to ensure appointments were not missed or they understood what was required of them.
  • The practice organised interpreters to be present at nurse clinics and nurses provided diagrams so patients better understood the procedure and treatment.

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.

  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider should make improvements are:

  • Review carer numbers to ensure all carers are identified

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care