Old Station Surgery

Updated 28 December 2023

Old Station Surgery is located in Ilkeston, Derby at:

Heanor Road

Ilkeston

Derby

DE7 8ES

It also has 2 branch sites:

• Kirk Hallam Surgery

Queen Elizabeth Way

Derbyshire

DE7 4NU

• Cotmanhay Surgery

1 Skeavingtons Lane

Derbyshire

DE7 8SX

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

The practice is situated within the Joined-Up Care Derbyshire Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of approximately 15,150 people. This is part of a contract held with NHS England.

The practice is part of the Erewash Primary Care Network (PCN), a wider network of 10 GP practices working collaboratively to deliver improved levels of care for patients, by connecting the primary healthcare team across the area with community and other service providers in their area.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 4th decile (4 out 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 area is predominantly white at 98.2% of the registered patients, with estimates of 0.6% Asian, 0.2% Black, 0.9% mixed, and 0.1% other.

The clinical team consists of 5 GP partners and 1 senior clinical pharmacist partner, 3 salaried GPs, a clinical pharmacist and pharmacy technician, 3 advanced nurse practitioners, 5 practice nurses (1 of whom is a nurse prescriber), a nurse associate, 2 GP assistants, 1 healthcare assistant and 2 phlebotomists.

The clinical staff are supported by a business practice manager, an operations manager, a finance officer, and a team of 22 reception and administration staff.

The practice supported placements for medical students. It has previously been a training practice supporting GP registrars, but this was on hold following the departure of the previous designated GP trainer.

The practice also has access to a range of other staff and services across their Primary Care Network (PCN) including additional pharmacy support, first contact physiotherapy and social prescribing.

The main site at Old Station Surgery is open between 8am to 6.30pm Monday to Friday, whilst the branches open from 8am to 6pm between Monday and Friday. The practice offers a range of appointment types including book on the day, telephone consultations, and advance-booked appointments. Home visits can be provided when these are required.

Patients can access additional appointments through the PCN’s extended access hub from 6.30pm to 8pm Monday to Friday, and on Saturday and Sunday mornings and bank holidays. The PCN also provide some limited on-the-day service appointments (8.30am to 6.30pm Monday to Friday) at Ilkeston Community Hospital and Littlewick Medical Centre.

Out of hours services are provided by Derbyshire Health United (DHU).

Updated 28 December 2023

We carried out an announced comprehensive inspection at Old Station Surgery on 14 November 2023. Overall, the practice is rated as requires improvement

Safe - requires improvement

Effective - requires improvement

Caring - good

Responsive - requires improvement

Well-led - requires improvement

At our previous comprehensive inspection on 6 October 2015, the practice was rated good overall and for the key questions of effective, caring, responsive and well-led. It was rated as requires improvement for providing safe services due to an absence of Legionella risk assessments for their 3 sites. A follow-up desk top review was undertaken on 15 July 2016 which found the provider to be compliant with regulations having completed the required risk assessments, so the practice was then also rated as good for safe.

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

Why we carried out this inspection.

We carried out this inspection due to our current inspection priorities. In this case, the practice was selected for inspection due to the length of time since our previous inspection.

How we carried out the inspection.

• An announced site visit.
• Conducting staff interviews using video conferencing prior to the site visit.
• Completing remote clinical searches on the practice’s patient records system and discussing findings with the provider (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 to be submitted electronically, and to review further evidence on site on the day of the inspection.
• Speaking with a member of the Patient Participation Group.

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:

• Patients received effective care and treatment that met their needs.
• The service was not always provided in a way to respond to patients’ needs, for example in terms of the ease making an appointment. However, we saw that the practice was participating in a comprehensive improvement programme which included improving patient experience with regards to access.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice did not always have effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• The practice did not always have effective processes for identifying, managing and responding to risks.
• There was limited evidence to demonstrate that clinical audit was driving improvement in patient outcomes.
• Some staff appraisals were overdue, and there were gaps in the completion of the practice’s mandatory training programme.

We found 1 breach of our regulations. The provider must:

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

In addition, the provide should:

• Continue to work on processes to enhance patient experience in terms of the ease of contacting the practice to make an appointment.

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