The Care Quality Commission
  • Doctor
  • GP practice

Hilltop Surgery

Overall: Good read more about inspection ratings

22 Maidenwell Avenue, Leicester, Leicestershire, LE5 1BL (0116) 276 955

Provided and run by:
Johnson Medical Practice

All Inspections

20 November 2023

During a routine inspection

We carried out an announced comprehensive inspection at Hilltop Surgery on 20 November 2023. Overall, the practice is rated as good.

Safe - good.

Effective - good.

Caring - good.

Responsive - good.

Well-led – good.

Following our previous inspection on 21 May 2015 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 Hilltop Surgery on our website at www.cqc.org.uk

Why we carried out this inspection.

We carried out this inspection in line with our inspection priorities.

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.
  • Staff questionnaires.

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 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.
  • The practice had effective clinical supervision in place.
  • The practice had an effective quality improvement programme used to encourage learning and development.
  • 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.
  • The practice had a strong emphasis on staff wellbeing and developing staff.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

  • Continue to engage with the population to improve the uptake of cervical screening and childhood immunisations.
  • Continue to engage with patients to obtain feedback in order to improve patients experience of the service. Including encouraging the development and uptake in the Patient Participation Group (PPG).

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

14 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hilltop Surgery on 14 November 2014. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, well-led, effective, caring and responsive services. It was also good for providing services for older people, people with long term conditions, families, children and young people, working age people (including those recently retired and students), people who circumstances may make them vulnerable, and people experiencing poor mental health.

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

  • Systems were in place to ensure the environment and equipment were clean and staff followed hygienic procedures to minimise the risk of infection.
  • The practice worked in partnership with midwives, health visitors and school nurses to share information, concerns, and best ways to support families.
  • Patients described the staff as friendly and caring, and said that they felt that they treated them with respect and dignity.
  • Patients were involved in decisions about their health and treatment, and received support to cope emotionally with their care and condition
  • There was good teamwork, leadership, and commitment to improving the quality of care and patients experiences.

However there were areas of practice where the provider needs to make improvements.

The provider should:

  • Update arrangements processes and systems to ensure that emergency medicines and equipment are available for the doctor’s bags.
  • Ensure the safeguarding adult’s policies and procedures and the whistleblowing policy are up to date and in line with internal reporting procedures. The whistleblowing policy should include contact organisations and current guidance on how to raise concerns at work.
  • Ensure that staff have the necessary knowledge and understanding in relation to the Mental Capacity Act 2005 to apply the principles of the Act when necessary.
  • The practice should review their arrangements for recruitment to ensure that appropriate risks assessments and checks are completed when necessary.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice