St Martins Practice

Updated 16 September 2022

St Martins Practice is located at 210-212 Chapeltown Road, Leeds, LS7 4HZ. The practice has good transport links and there is a co-located pharmacy within the building.

The provider is registered with the Care Quality Commission (CQC) to deliver the following Regulated Activities:

Diagnostic and screening procedures

Family planning

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

The practice is situated within the NHS West Yorkshire Integrated Care Board (ICB) and provides services to 7,420 patients under the terms of a Personal Medical Services (PMS) contract. This is a contract between general practices and NHS England for the delivery of services to the local community.

The service is provided by a partnership consisting of one business partner and five GP partners (three female and two male), three salaried GPs (female), one diabetes nurse specialist, three practice nurses and a healthcare assistant (all female). The clinical team are supported by an experienced patient support team.

The practice is part of the Chapeltown Primary Care Network (PCN). PCNs are a group of practices working together to focus care on the needs of the local population.

The National General Practice Profile states that the practice patient population is made up of 53% white 20% Asian and 27% originating from black, mixed or other non-white ethnic groups.

Information published by Public Health England, rates the level of deprivation within the practice population as three, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.

The practice is open between 8am and 6pm Monday to Friday. In addition, in-house extended hours are available between 6pm and 8.15pm on Tuesday evenings. The practice offers urgent same day appointment booking and some routine appointments.

Extended access is provided locally, where routine weekend appointments are available. Out of hours services are provided by NHS111.

Updated 16 September 2022

We carried out an announced comprehensive at St Martins Practice on 10 and 11 August 2022. Overall, the practice is rated as good.

Safe - Good

Effective - Good

Caring - Good

Responsive – Good

Well-led - Good

Following our previous inspection on 24 November 2015, the practice was rated Good overall and for providing safe, effective, caring and well-led services. We rated the practice Outstanding for providing responsive services.

At the last inspection we rated the practice as Outstanding for providing a responsive service because:

• They had proactively initiated and lead on a number of innovative services to meet the needs of the local community.

At this inspection, we found that those areas previously regarded as outstanding practice were now embedded throughout the majority of GP practices. While the provider had maintained this good practise, the threshold to achieve an outstanding rating had not been reached. The practice is therefore now rated Good for providing a Responsive service.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for St Martins Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this comprehensive 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 in person and using video conferencing.
• Staff questionnaires sent to staff ahead of the inspection
• 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.

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.
• The practice understood the needs of the local population and were committed to providing services to support this group of patients.
• The practice was committed to continuous learning and improvement and engaged with a number of projects including the Primary Care Network (PCN) project 3 Treatment Target for Diabetes and the improving mental health of black men inequalities project.
• We saw evidence of numerous two-cycle audit activity, a whole practice approach to reviewing and learning from significant events and incidents and clear evidence of improvements to practice as a result of audit and learning from significant events.
• There was a strong focus on maintaining relationships with patients. The staff had worked with patients and staff to introduce social contracts to address challenging behaviours from patients and ensure staff were able to understand and empathise with patients.
• Patients received effective care and treatment that met their needs.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

We saw areas of outstanding practice:

• The practice had signed up to the Doctors of the World Safe Surgeries Scheme which focused on tackling the barriers faced by migrants accessing healthcare.
• The practice was a hub service for city wide substance misuse and hosted a support service at the practice for black and minority ethnic (BME) family, friends and relatives affected by the alcohol use of an adult. The practice had supported two GPs to complete a substance misuse courses to support this service.

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

• Take action to ensure clinical and non-clinical staff undertake the appropriate level of safeguarding training.
• Update the prescribing process for Methotrexate to include the day of the week on which the patient should take the medication recorded on their prescription.
• Improve the recall process for patients on Amiodarone and include all required monitoring during the review.
• Review the process for ongoing management of historical safety alerts (e.g. Medicines and Healthcare Products Regulatory Agency).
• Take steps to ensure that records of patients with potential missed diagnoses of chronic kidney disease are properly coded and ensure that all required monitoring checks are carried out.
• Improve the recall system in place for patients with hypothyroidism to include thyroid function checks at birthday month reviews and identify any patients that are overdue monitoring.