Background to this inspection
Updated
21 May 2021
Shaftesbury Medical Centre is located in Leeds at:
78 Osmondthorpe Lane
Leeds
West Yorkshire
LS9 9EF
The practice has a branch surgery at:
Church View Surgery
Crossgates Medical Centre, 2nd floor
Station Road
Leeds
LS15 8BZ
As part of the inspection we visited both these locations.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, treatment of disease, disorder or injury, family planning, maternity and midwifery services and surgical procedures. These are delivered from both sites.
The practice offers services from both a main practice and a branch surgery. Patients can access services at either surgery. However, during the pandemic the branch site has been operating as a “red site”, where either COVID-19 positive or potentially COVID-19 symptomatic patients have been seen as necessary.
The practice is situated within the Leeds Clinical Commissioning Group (CCG) and delivers Personal Medical Services (PMS) to a patient population of approximately 17,400. This is part of a contract held with NHS England. The practice is part of a wider network of GP practices known as a primary care network (PCN).
The practice has eight GP partners and four salaried GPs. There is a team of nursing staff, which consists of practice nurses, healthcare assistants and a nurse manager. Clinical staff are supported by an administration team, consisting of reception/administration staff, medical secretaries, practice manager, business manager and an IT team. During the pandemic staff had been risk assessed and based at one of the two sites.
Information published by Public Health England report deprivation within the practice population group as one on a scale of one to 10. Level one represents the highest levels of deprivation and level 10 the lowest.
There is a mixed age range of patients, who are predominantly from a white background. They have a higher than local and national average of patients who have depression (18% compared to local 10.8% and national 11.6%) and obesity (14.5% compared to 10.6% local and 10.5% national).
The average life expectancy of the practice population is lower than the national average for both males and females (77 years for males, compared to the national average of 79 years and 81 years for females compared to national average of 83 years.)
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments are telephone consultations. However, patients who need to be seen face to face are offered an appointment at one of the practice locations, as befits their need. At the time of our inspection, the practice was looking at how they can move towards more face to face appointments in line with pandemic guidance.
Extended access is provided locally, where late evening and weekend appointments are available. Out of hours services are provided by Local Care Direct.
Updated
21 May 2021
We carried out an announced focused inspection at Shaftesbury Medical Centre on 28 April 2021.
We focused our inspection on the key question of:
The practice remains rated as good overall and now good for providing safe services.
Following our previous inspection on 7 November 2019, the practice was rated as good overall and for the key questions of effective, caring, responsive and well-led. The practice was rated as requires improvement for providing safe service, with a breach of Regulation 12 of the Health and Safety Care Act 2008 (Regulated Activities) Regulations 2014 safe care and treatment.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Shaftesbury Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
In November 2020 we had undertaken a monitoring call with the provider, where we were informed that they had completed all the actions relating to the breach of Regulation 12.
This was a focused inspection to check those actions had been completed and were embedded throughout the practice.
At the last inspection we found:
- Storage of vaccines in the refrigerators was not in line with best practice and that some vaccines had expired.
- Sharps waste was not managed in line with best practice.
- Some expired medicines and other products, including vaccines, swabs, sterile bags and oxygen masks.
- Arrangements to respond to emergencies were not well embedded within the practice. At the branch location, some emergency medicines were stored in separate areas, which could have delayed the administration of those medicines in an emergency.
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:
- A site visit to both locations.
- A review of documents specific to the issues identified at the previous inspection.
Our findings
We found that the practice had made the necessary improvements:
- Vaccines were stored in line with best practice. We observed that vaccines were in date and there was a clear process regarding stock control and the checking of expiry dates. Expired vaccines were disposed of in line with relevant guidance.
- Sharps waste was managed in line with best practice. There was a clear process for the management and storing of sharps waste. All sharps waste bins were labelled and stored securely.
- There was a clear process for the management of medicines and products, such as swabs and oxygen masks, to ensure they were all in date.
- Emergency medicines and equipment were stored together in a secure room. Staff knew how to access them should they be needed in an emergency.
- All improvements had been implemented across both of the practice locations.
- Staff were aware of the improvements, which had been embedded within the practice.
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