Archived: Melbourne Road Health Centre - R Kapur

Updated 11 July 2016

Melbourne Road Health Centre – R Kapur provides primary medical services to approximately 2,964 patients in Leicester City.

It is registered with the Care Quality Commission to provide the regulated activities of; the treatment of disease, disorder and injury; diagnostic and screening procedures; family planning; maternity and midwifery services and surgical procedures.

At the time of our inspection the practice employed two GPs and two locum GPs (two male and one female), one practice manager, one senior receptionist, two receptionists, one administrator/health care assistant (HCA),

The surgery is open from 8am until 6.30pm Monday to Friday. The practice provides extended opening hours on a Saturday from 9am until 3pm. The practice is part of a pilot scheme within Leicester City which offers patients an evening and weekend appointment with either a GP or advanced nurse practitioner at one of four healthcare hub centres. Appointments are available from 6.30pm until 10pm Monday to Friday and from 9am until 10pm on weekends and bank holidays. Appointments are available by walk in, telephone booking or direct referral from NHS 111.

The practice has a General Medical Services (GMS) contract. The GMS contract is the contract between general practices and NHS England for delivering care services to local communities.

The practice is registered with the Care Quality Commission (CQC) to provide regulated activities at Melbourne Road Health Centre - R Kapur, 47 Melbourne Road, Leicester, LE2 0GT. The practice is located in an end terrace converted property which consists of a patient waiting area and consulting rooms on both the ground floor and first floor.

The practice has an active patient participation group (PPG) who meet on three monthly regular basis. The practice has a higher population of patients between the ages of 0-18 years of age.

The practice offers on-line services for patients including ordering repeat prescriptions, booking routine appointments and access to summary care record.

The practice lies within the NHS Leicester City Clinical Commissioning Group (CCG). A CCG is an organisation that brings together local GPs and experienced health professionals to take on commissioning responsibilities for local health services.

Updated 11 July 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Melbourne Road Health Centre – R Kapur on 21 March 2016. Overall the practice is rated as requires improvement

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

• Data from the Quality and Outcomes Framework showed patient outcomes were above average for the locality and the national average.

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

• Not all risks to patients were assessed and well managed. The practice did not have a carpet cleaning schedule in place. Not all areas of the practice were cleaned in line with the practice cleaning schedule and guidelines.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.

• The practice had a number of policies and procedures to govern activity.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.

• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Ensure appropriate systems and processes are in place relating to infection control in line with national guidance, ensuring consulting and treatment rooms are cleaned as per practice cleaning schedule and guidelines and implementation of carpet cleaning schedules.

• Ensure a suitable fire detection and alarm system is installed to ensure compliance with the action plan served by Leicestershire Fire Service (LFS).  Ensure fire risk assessment is effective and all hazards are identified.

• Ensure the property is appropriately maintained and remedial repairs carried out to ensure the health and safety of staff, patients and visitors.

• Ensure procedures for monitoring and recording of water temperatures are in place, in line with the practice Legionella risk assessment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 11 July 2016

The practice is rated as requires improvement for the care of people with long-term conditions. The practice was rated as good for being caring, effective and responsive. However it was rated as requires improvement for providing safe care and for being well led. The concerns which led to these ratings apply to everyone using the practice, including this population group

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.

• Performance for diabetes related indicators was 91.4% which was better than the national average 89.2%. (exception reporting rate was 8.8%).

• Longer appointments and home visits were available when needed.

• All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Updated 11 July 2016

The practice is rated as requires improvement for the care of families, children and young people. The practice was rated as good for being caring, effective and responsive. However it was rated as requires improvement for providing safe care and for being well led. The concerns which led to these ratings apply to everyone using the practice, including this population group

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.

• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.

• The practice’s uptake for the cervical screening programme was 83%, which was higher than the CCG average of 73.3% and the national average of 74%.

• Appointments were available outside of school hours and the premises were suitable for children and babies.

• Childhood immunisation rates for the vaccinations given were comparable to CCG/national averages. For example, childhood immunisation rates for the vaccinations given to under two year olds ranged from 87.5% to 100% and five year olds from 73% to 94.6%.

Updated 11 July 2016

The practice is rated as requires improvement for the care of older people. The practice was rated as good for being caring, effective and responsive. However it was rated as requires improvement for providing safe care and for being well led. The concerns which led to these ratings apply to everyone using the practice, including this population group.

• The practice offered proactive, personalised care to meet the needs of the older people in its population.

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.

Updated 11 July 2016

The practice is rated as requires improvement for the care of working-age people (including those recently retired and students). The practice was rated as good for being caring, effective and responsive. However it was rated as requires improvement for providing safe care and for being well led. The concerns which led to these ratings apply to everyone using the practice, including this population group

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.

• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

• The practice provided extended opening hours on a Saturday from 9am until 3pm each week.

• We saw positive examples of joint working with midwives, health visitors and school nurses.

Updated 11 July 2016

The practice is rated as requires improvement for the care of people experiencing poor mental health (including people with dementia). The practice was rated as good for being caring, effective and responsive. However it was rated as requires improvement for providing safe care and for being well led. The concerns which led to these ratings apply to everyone using the practice, including this population group

• Performance for mental health related indicators was 80.9% which was worse than the national average of 92.8%. (exception reporting rate was 8.6%).

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.

• The practice carried out advance care planning for patients with dementia.

• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

• The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

• Staff had a good understanding of how to support patients with mental health needs and dementia.

Updated 11 July 2016

The practice is rated as requires improvement for the care of people whose circumstances may make them vulnerable. The practice was rated as good for being caring, effective and responsive. However it was rated as requires improvement for providing safe care and for being well led. The concerns which led to these ratings apply to everyone using the practice, including this population group

• The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.

• The practice offered longer appointments for patients with a learning disability.

• The practice regularly worked with other health care professionals in the case management of vulnerable patients.

• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.

• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.