We carried out an announced comprehensive inspection of The North Leeds Medical Practice, 355 Harrogate Road, Leeds, West Yorkshire LS17 6PZ between 16 August and 24 August 2021.
We have rated the practice as follows:
Overall, the practice is rated as Requires Improvement. With the key questions rated as:
Safe – Requires Improvement
Effective – Requires Improvement
Caring - Good
Responsive - Good
Well-led – Requires Improvement
Following our previous inspection on 18 July 2019, the practice was rated as good overall and for the key questions of effective and well-led. At that time, the ratings of good for the key questions of safe, caring and responsive were carried over from an earlier inspection.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for The North Leeds Medical Practice on our website at www.cqc.org.uk
Why we carried out this inspection
As a result of concerns we had received, we carried out a focused inspection on 16 August 2021, concentrating on whether the provider was delivering safe and well-led care. During that inspection we identified additional concerns and subsequently carried out a comprehensive inspection of the service on 24 August 2021.
How we carried out the inspection
Throughout the pandemic the Care Quality Commission (CQC) has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Requesting evidence from the provider pre and post inspection.
- Completing clinical searches on the practice electronic patient records system.
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Conducting staff interviews via telephone calls.
- The completion of interview question templates by practice staff.
- Undertaking site visits.
Our findings
We based our judgement of the quality of care at this service on a combination of:
- what we found when we inspected and on the site visits
- information from our ongoing monitoring of data about services
- information from the provider, patients, the public and other organisations.
We have rated this practice as Requires Improvement overall and also the population groups of families, children and young people and working age people (including those recently retired and students).
At the time of our inspection we found that:
- The practice had adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients had access to a range of appointments which included telephone, video, face-to-face or home visits. Extended and weekend access was available via local practice hubs.
- Patients received care and treatment in line with local and national guidance.
- There had been consistently lower than the local and national average uptake rates for childhood immunisations and cervical cancer screening.
- Patient referrals to other services had been managed to avoid any delays or backlogs. Actions relating to pathology results and discharge summaries were up to date.
- Medicines were prescribing in line with guidance. Antimicrobial prescribing was positive, compared to local and national figures. However, the practice did not have a system in place to demonstrate the competency of non-medical prescribers and those staff employed in advanced clinical practice.
- Recruitment processes had not always been undertaken in line with guidance, such as obtaining a Disclosure and Barring Service check prior to employment and recording the immunisation status of staff.
- There was a comprehensive induction package in place for newly employed staff. Staff reported they had access to support and mentorship as needed and received annual appraisals.
- Not all risk assessments relating to health and safety and fire had been actioned appropriately. There was no risk assessment in place regarding the security of the two practice locations.
- Staff knew how to report incidents. We saw that incidents had been dealt with, however, there was no process in place to identify any learning or sharing details with staff.
- The practice held daily clinical catch-up meetings where any issues relating to patients or the premises could be discussed.
- Patient survey data reported good satisfaction rates, compared to other local and national GP practices.
- The practice had an active patient participation group who were meeting virtually and provided support to patients as needed.
- Leaders had identified some areas for improvement and an action plan had been developed as to how they would be resolved. However, we had identified additional issues, arising from our inspection visit. These were also added to the action plan.
- Staff were not aware of the vision, values and strategy of the practice and there was no system in place to monitor progress against the delivery of the strategy.
- Staff reported they were able to raise concerns and felt confident to do so. However, they were not aware of who the Freedom to Speak Up Guardian was.
- Staff reported some of the difficulties arising from the absence of a regular and permanent practice manager. Some of the processes to support safe and effective governance were not always reviewed and in place. For example, policies and procedures and risk assessments.
- The practice had contacted the local Clinical Commissioning Group and Primary Care Network to seek advice and support regarding the issues that had been identified.
- The practice promoted and supported a positive, open and honest culture. This was apparent when speaking to staff.
We found two breach of regulations. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
- Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
Additionally, the provider should:
- Review how they can improve uptake rates for childhood immunisations and cervical cancer screening.
- Maintain records to demonstrate that staff are vaccinated in line with Public Health England guidance.
- Complete all outstanding areas identified in the practice action plan and risk assessments.
- Promote awareness of the Freedom to Speak Up Guardian and inform staff of who this person is and how they can be accessed.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care