The Care Quality Commission
  • Doctor
  • GP practice

The Osmaston Surgery Also known as Dr I R Shand & Partners

Overall: Requires improvement read more about inspection ratings

212 Osmaston Road, Derby, Derbyshire, DE23 8JX (01332) 346433

Provided and run by:
The Osmaston Surgery

All Inspections

During an assessment under our new approach

The Osmaston Surgery provides care to a population of approximately 13,660 patients in Derby. At our assessment in June 2023, the practice was placed into special measures and rated inadequate overall and in the key questions safe, effective, responsive, well-led and requires improvement for caring. We carried out a follow-up assessment of this service from 17 May to 18 June 2024 to assess all of the quality statements in each key question. We found there were now systems in place to support learning from incidents and safeguarding, teams and services worked together to provide continuity of care. There had also been some improvements in the management of medicines. However, there continued to be a breach in Regulation 12, safe care and treatment, and Regulation 17, good governance. There continued to be issues regarding the management of patients with asthma, the management of patients prescribed medicines that required monitoring and medicine reviews were not always up to date. There continued to be limited clinical audit activity; gaps in staff training; a lack of systems to track prescription stationery throughout the practice; cervical screening and childhood immunisations continued to be below national targets; there was limited engagement with patients or staff to seek their views. In addition we found that risk assessments had not been completed when the immunisation status of 2 clinicians working in the practice was not recorded in their records and policies were not always adhered to, for example complaints and recruitment. The practice is now rated requires improvement overall and in the key questions safe, responsive and well led, and good in effective and caring. We are taking this service out of special measures. This recognises the improvements that have been made to the quality of care provided by this service. We have asked the provider for an action plan in response to the 2 breaches of regulation we found at this assessment.

5 June 2023

During a routine inspection

We carried out an unannounced comprehensive inspection at The Osmaston Surgery on 5 June 2023. Overall, the practice is rated as inadequate.

Safe - inadequate

Effective - inadequate

Caring - requires improvement

Responsive - inadequate

Well-led - inadequate

Following our previous inspection on 24 May 2018, 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 The Osmaston Surgery on our website at www.cqc.org.uk

Why we carried out this inspection.

We carried out this inspection to follow up concerns reported to us.

How we carried out the inspection.

  • An unannounced site visit.
  • Conducting staff interviews.
  • 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.

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 did not ensure care and treatment was provided in a safe way to patients.
  • The practice had not established effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • The service was not provided in a way to care and respond to patients’ needs.

We found 2 breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provide should:

  • Review access to appointments and continue to develop sustainable improvements to improve patient experience.
  • Improve the uptake of childhood immunisations and cancer screening.

As a result of the inspection team’s findings from the inspection, as to non-compliance, but more seriously, the risk to service users’ life, health and wellbeing, the Commission decided to issue an urgent notice of decision to impose conditions on the provider’s registration. The notice was served on the provider on 13 June 2023 and took immediate effect.

I am placing this service in special measures. Services placed in special measures will be inspected again within 6 months. If insufficient improvements have been made such that there remains a rating of inadequate for any 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 6 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 6 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

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

24 May 2018

During a routine inspection

We carried out an announced comprehensive inspection at The Osmaston Surgery on 12 February 2016. The overall rating for the practice was good with requires improvement for providing effective services. A breach of legal requirement was found and requirement notice in relation to safe care and treatment issued. The full comprehensive report on the February 2016 inspection can be found by selecting the ‘all reports’ link for The Osmaston Surgery on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 24 May 2018 to confirm that the practice met the legal requirement in relation to the breach in regulation that we identified in our previous inspection on 12 February 2016.

Our key findings are as follows:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice identified learning from them. However, not all staff were fully engaged in process of learning from significant event and complaint reviews as they didn’t attend the meetings.
  • The practice worked closely with other health and social care professionals involved in patient’s care. Regular meetings with the community health and social teams and palliative care teams were held to discuss the care of patients who were frail / vulnerable or who were receiving end of life care. The practice met regularly with the health visitor and midwife leads to discuss children at risk.
  • The practice had carried out clinical audits to review the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines. The audits seen demonstrated quality improvements.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • The practice had reviewed the results of the national GP survey published in July 2017 and developed an action plan to improve results.
  • The practice provided a range of appointments, including ‘drop in’ clinics every day. Patients told us they could usually get an appointment when they needed one.

There were areas of practice where the provider should make improvements..

The provider should:

  • Update the safeguarding policies to include information about modern slavery and the contact details for
  • Demonstrate the competence of staff employed in advanced roles by audit of their clinical decision making.
  • Promote staff engagement in the sharing of learning from significant event and complaint reviews.
  • Document the risk assessments for
  • Carry out a risk assessment to assess whether they needed to keep medicine to treat croup in children in stock
  • Share the practice vision with the staff team.
  • Fully utilise all opportunities for learning and improving performance.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

12 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Osmaston Surgery on 12 February 2016. Overall the practice is rated as good.

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

  • The appointment system was flexible and ensured that patients who requested to be seen on the same day were.

  • The practice had good facilities including disabled access. Patients who could not manage the stairs were seen on the ground floor.

  • Information about services and how to complain was available, however, not in a format that could be understood by all patients. The practice sought patient views about improvements that could be made to the service, including having a patient participation group (PPG).

  • The practice used interpreting services enabling patients whose first language was not English to access the services available. However, access to written information in other languages was not readily available.

  • The practice proactively managed care plans for some vulnerable patients and had effective management strategies for patients at the end of their life.

  • There were systems in place to reduce risks to patient safety for example, infection control procedures.

  • Staff identified a clear leadership structure, good team work, and felt supported by the management.

  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. There was a training programme however; training in the Mental Capacity Act 2005 had not been provided. Senior staff provided assurance of their competencies in mental capacity assessment through case examples.

  • The practice performance in relation to the management of patients with long term conditions, learning disabilities, and people experiencing mental health was mixed and exception reporting in these areas was high. The practice staff were unable to inform us what they would do to try and reduce this.

The areas where the provider must make improvement are:

  • Take proactive steps to ensure patients receive safe care and treatment by reviewing exception reporting to mitigate the risks to ensure their health and wellbeing.

  • Ensure patients with learning disabilities receive an annual health review with care plans written.

  • Improve the identification of and support to carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice