The Care Quality Commission
  • Doctor
  • GP practice

The Light

Overall: Good read more about inspection ratings

Balcony Level, The Light, The Headrow, Leeds, West Yorkshire, LS1 8TL (0113) 242 7425

Provided and run by:
One Medicare Ltd

All Inspections

During an assessment under our new approach

The Light Surgery is an NHS GP practice which provides primary care services to patients in an area of Leeds, West Yorkshire. We carried out an announced assessment of one quality statement, equity of access, under the key question Responsive at the Light Surgery on the 11 March 2024. We carried out the assessment as part of our work to understand how practices are working to try to meet peoples demands for access and to better understand the experiences of people who use services and providers. We recognise the work that GP practices have been engaged in to continue to provide safe, quality care to the people they serve. We know staff are carrying this out whilst the demand for general practice remains exceptionally high, with more appointments being provided than ever. However, in this challenging context, access to general practice remains a concern for people. Our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. The assessment of the quality statement equity of access includes looking at what practices are doing innovatively to improve patient access to primary care and sharing this information to drive improvement. Overall, the practice is rated as good and the key question responsive continues to be rated as providing a good service. We found that the practice had organised services to meet patients’ needs, particularly those who were most likely to have difficulty accessing care, so that people can access care, treatment and support when they need it and in a way that works for them. The practice sought out and used feedback and other data/information to monitor and improve access.

11 August 2022

During a routine inspection

We carried out an announced comprehensive inspection at The Light on 11 August 2022. Following this inspection, we rated the location as Good and the following for each key question:

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 15 February 2019, 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 Light on our website at www.cqc.org.uk

Why we carried out this inspection

This comprehensive inspection was undertaken as a result of identified risk; as indicated by CQC data analyst systems.

How we carried out the inspection

Throughout the pandemic 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 as possible. 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.
  • Conducting some staff interviews via telephone and teleconferencing.
  • Practice staff completing questionnaires.
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • A site visit.

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 have rated this practice as Good overall

We found that:

  • There were systems in place to safeguard children and vulnerable adults from abuse and staff knew how to identify and report safeguarding concerns.
  • Leaders reviewed the effectiveness and appropriateness of the care the service provided. They ensured that care and treatment was delivered according to evidence-based guidelines.
  • The practice had adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • Staff had the skills, knowledge and experience to deliver effective care.
  • The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

  • Summarise any outstanding patient records to ensure that all information is available for the delivery of safe patient care and treatment.
  • Continue to look at ways of improving uptake rates for childhood immunisations and cancer screening of breast, bowel and cervical.
  • Continue to review and improve patient satisfaction, particularly relating to access.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

15 Feb to 15 Feb 2019

During a routine inspection

This practice is rated as Good overall. The practice was previously inspected in January 2016 when it was rated Good overall.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at The Light on 15 February 2019. This inspection was planned and undertaken as part of our inspection programme and as part of a wider inspection of the provider (One Medicare Ltd). The provider had agreed to contribute to our Primary Care at Scale project.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The provider produced a monthly lessons learned bulletin to share themes and learning from significant events and complaints across all locations.
  • The practice offered a number of additional in-house services such as social prescribing, physiotherapy and a mental health support worker.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.

We saw one area of outstanding practice:

  • The practice promoted healthy living and offered patients access to a health coach, gym facilities and provider led boot camps.

The area where the provider should make improvements are:

  • Continue to review access and the appointment system to improve patient satisfaction.
  • Continue to review and improve uptake of cancer screening programmes.
  • Continue to review and improve exception reporting rates for people with a long-term condition.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

19 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Light Surgery on 19 January 2016. Overall the practice is rated as good for providing safe, effective, caring, responsive and well-led care for all of the population groups it serves.

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

  • There was an open and transparent approach to safety and an effective system was in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and were involved in care and decisions about their treatment.
  • The practice had good facilities and was well equipped to treat and meet the needs of patients.
  • The practice sought patient views how improvements could be made to the service, through the use of patient surveys, the NHS Friends and Family Test and the patient participation group.
  • Information about services and how to complain was available and easy to understand.
  • There was a clear leadership structure and staff were supported by management.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

We saw one area of practice where the practice should make improvements:

  • Ensure that all clinical waste bags are securely tied and labelled to ensure no clinical waste spillage prior to collection from the appropriate authority.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice