We carried out a review of the data available to us about Leesbrook Surgery 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 Leesbrook Surgery, you can give feedback on this service.
This practice is rated as Good overall.
We first carried out an announced comprehensive inspection at Leesbrook Surgery on 15 March 2016. The overall rating for that inspection was inadequate and the practice was placed into special measures.
A further announced comprehensive inspection was carried out on 12 January 2017. During that inspection it was found that improvements had been made. The practice was given an overall rating of good and was taken out of special measures.
The full comprehensive reports on the March 2016 and January 2017 inspections can be found by selecting the ‘all reports’ link for Leesbrook Surgery on our website at www.cqc.org.uk.
This announced full comprehensive inspection was carried out on 10 November 2017 in accordance with our inspection methodology. The practice is rated as good.
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people with dementia) - Good
At this inspection we found:
The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
Staff involved and treated patients with compassion, kindness, dignity and respect.
Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
There was a strong focus on continuous learning and improvement at all levels of the organisation.
The areas where the provider should make improvements are:
The provider should ask potential employees about gaps in their employment history.
The provider should carry out a fire evacuation, and also revert to carrying out weekly fire alarm checks.
The provider should make further improvements to their administration and documentation. For example, learning from complaints should be documented, meeting minutes should contain enough information for staff and audit programme where audits are repeated to monitor improvement would be helpful.
The provider should evaluate their policies to avoid duplication and complication.
The provider should continue the process of having all partners correctly registered.
The provider should check data protection arrangements, especially relating to computer smart cards and password.
We first carried out an announced comprehensive inspection at Leesbrook Surgery on 15 March 2016. The ratings for this inspection were:
Safe – Inadequate
Effective – Inadequate
Caring – Good
Responsive – Requires improvement
Well led – Inadequate
The overall rating for the practice was inadequate and the practice was placed in special measures. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Leesbrook Surgery on our website at www.cqc.org.uk.
Following the inspection on 15 March 2016 two warning notices were issued to Leesbrook Surgery in respect of the need for consent and fit and proper persons employed. We carried out a follow up inspection on 20 September 2016 and found the practice had met the requirements of the warning notices.
This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 12 January 2017. Overall the practice is now rated as good.
Our key findings were as follows:
However, there were also areas of practice where the provider needs to make improvements.
The areas where the provider must make improvements are:
The provider must mitigate risks to patients. All actions identified as part of their fire risk assessment must be completed, and appropriate fire safety checks must be carried out at the correct intervals.
The provider must ensure clinical waste is stored securely and not accessible by patients or members of the public.
In addition:
The provider should review all polices so they contain accurate information and are practice specific.
The provider should check their guidance relating to complaints is up to date and accurate.
The provider should put a system in place so all blood test results where the blood test has been carried out in hospital are stored so they are easily accessible to clinicians accessing records.
The provider should include all partners on their CQC registration.
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.
Chief Inspector of General Practice
On 15 March 2016 we carried out a full comprehensive inspection of Leesbrook Surgery. This resulted in two Warning Notices being issued against the provider on 29 April 2016. The Notices advised the provider that the practice was failing to meet the required standards relating to Regulation 11 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014, Need for consent, and Regulation 19 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014, Fit and proper persons employed.
On 20 September 2016 we undertook a focused inspection to check that the practice had met the requirements of the Warning Notices. At this inspection we found that the practice had satisfied the requirements of the Notice.
Specifically we found that:
Following the previous inspection a GP partner had given awareness training to staff on issues relating to consent. This included awareness of the Gillick competence and The Mental Capacity Act 2005. The Gillick competence is used to decide whether a child (16 years or younger) is able to consent to his or her own medical treatment, without the need for parental permission or knowledge. The Mental Capacity Act 2005 protects people aged 16 and over who lack the capacity to make decisions themselves. Written information was also given to staff.
Further training was provided to staff in June 2016 by an external provider.
The understanding of staff on issues relating to consent had been tested following their training. In addition, the member of the nursing team we spoke with had a good understanding of all matters relating to consent.
Consent and issues relating to the Mental Capacity Act 2005 had been discussed at clinical meetings.
No new staff had been recruited since the previous inspection. Two new staff were in the process of being recruited. The recruitment procedure was being followed to ensure all required checks and documents were held.
Relevant information was held for all clinicians. This included a current Disclosure and Barring Service (DBS) check and evidence of professional registration.
The rating awarded to the practice following our full comprehensive inspection on 15 March 2016 remains unchanged. The practice will be re-inspected in relation to their rating in the future.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Leesbrook Surgery on 15 March 2016. Overall the practice is rated as inadequate.
Our key findings across all the areas we inspected were as follows:
The areas where the provider must make improvements are:
The provider must ensure adequate recruitment checks take place, including having a full employment history of new staff, and reasons for leaving previous employment where appropriate.
The provider must ensure all staff are trained in safeguarding to the appropriate level and know how to access support if they have a safeguarding concern.
The provider must ensure relevant staff are aware of the Gillick Competence, and treat patients with dignity and respect. The provider must also ensure staff are aware of the Mental Capacity Act 2005, so consent is obtained appropriately or capacity formally assessed where required.
The provider must ensure they have an adequate complaints procedure that is brought to the attention of patients. Complaints should be reviewed and all required information should be given to patients when their complaint is responded to.
The provider must ensure procedures are in place to identify risks. For example, clinical supplies must be within their expiry date and adequate infection control procedures must be in place. Where risks are identified, for example following infection control audits, action plans should be put in place and monitored to ensure improvements take place.
The provider must ensure that all emergency medicines are easily accessible in an emergency.
The provider must ensure all staff receive appropriate training that is delivered effectively.
In addition:
The provider should improve their procedures for identifying issues and making improvements to the service provided.
The provider should maintain an up to date relevant website.
I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.
The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.
Special measures will give people who use the service the reassurance that the care they get should improve.
Chief Inspector of General Practice
We carried out a follow-up inspection on 7 January 2014 and re-visited on 17 January 2014 because all the required evidence was not initially available.
We found that by 17 January 2014 Disclosure and Barring Service (DBS) checks had been requested for all appropriate staff and some had been returned. Evidence of identity for staff had also been obtained. Clinical staff had completed training on the prevention of infection and control. The provider told us it had not been possible to train non-clinical staff. Examination couches had been re-covered where required. Infection control audits had also started to be carried out.
Patients were provided with appropriate information and support to understand the treatment available to them. New patients registered with the practice were assessed and given appropriate advice. Care plans were in place to reduce the risk of patients being admitted to hospital during the winter months. Some formal and informal checks were carried out to monitor the quality of the service. We saw evidence of improvements being made following these checks. .
The examination couches in three of the rooms we looked at had small tears in the vinyl covering. This presented a risk of infection because the covers could not be cleaned effectively. Not all staff had been trained in the prevention and control of infection.
During the recruitment process the identity and work history of new staff was not routinely checked. Criminal Record Bureau (CRB) or Disclosure and Barring Service (DBS) checks had not been carried out for new staff who had direct contact with patients.
The patients we spoke with gave positive comments about the service. They included 'I've always thought the service was great. Receptionists always look at you and smile, not like at my last practice', 'I've seen all the doctors here and they are all brilliant' and 'Doctors always explain things in a way I understand. If they didn't I would ask'.