Lupset Health Centre

Updated 23 August 2022

Lupset Health Centre is located in Wakefield at:

George A Green Court

Wakefield

West Yorkshire

WF2 8FE

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.

The practice is located over two floors and is accessible for those with a physical disability, as floor surfaces are level, entrance doors are automatic and wide allowing access for patients using wheelchairs. Consulting and treatment rooms are all located on the ground floor with the upper floor used for administration, meeting and educational purposes. There is parking available on the site for patients, and a privately operated pharmacy is located adjacent to the practice building.

The practice is situated within the Wakefield District Health & Care Partnership, and delivers Personal Medical Services (PMS) to a patient population of 14,000. In addition to general GP services the practice provides “Safe Haven” services for a small number of patients who have been excluded from other GP practices.

The practice is part of a wider network of GP practices as part of the West Wakefield Primary Care Network. This comprises a partnership of GP practices who work together to improve patient care within their locality.

Information published by Public Health England shows that deprivation within the practice population group is in the third lowest decile (three of 10). The lower the decile, the more deprived the practice population is relative to others. The practice population is mainly of white British origin.

Attached to the practice or closely working with the practice is a team of community health professionals that includes health visitors, midwives and members of the community nursing team.

There are eight GP partners, three salaried GPs, and five GP Registrars. There are two nurse practitioners, five practice nurses, one learning disability nurse, and four health care assistants. Other clinical resource is provided to the practice from their primary care network (PCN), this includes pharmacists, pharmacy technicians and a first contact physiotherapist. Supporting these clinicians is a reception and administration team led by a practice manager. The practice is accredited as a GP training centre supporting doctors training to specialise in general practice, and also provides placements for student nurses.

The practice is open between 7:30am to 6:30pm Monday, Tuesday, Wednesday and Friday, and on Thursday from 8am to 8:30pm. Appointment times vary throughout the week. The practice offers a range of appointment types including urgent, book on the day, telephone consultations, online consultations, advance appointments and home visits.

Other extended access is provided for patients, where late evening and weekend appointments are available at other practices in the Wakefield area. Appointments for these services are available 3:30pm to 9:30pm Monday to Friday, 9am to 4pm Saturdays, and 9am to 1pm Sundays. Out of hours services are provided by Local Care Direct Limited.

Updated 23 August 2022

We carried out an announced inspection at Lupset Health Centre between 21 July 2022 and 22 July 2022. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 15 November 2017, the practice was rated Good overall and for all key questions except Responsive which was rated as Outstanding.

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

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.

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. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting some staff interviews using video/telephone conferencing.
• 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 .
• Requesting evidence from the provider.
• A short site visit.
• Reviewing completed staff questionnaires.

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:

• There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• 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 adjusted how services were delivered to meet the needs of patients during the COVID-19 pandemic.
• There was a programme of quality improvement, this included both clinical and non-clinical audit.
• Staff had the skills, knowledge and experience to deliver effective care. The practice had a strong training ethos. They operated as a GP training practice, provided placements for student nurses, and had supported a number of staff in the development of their professional careers.
• The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Leaders and managers in the practice demonstrated they had the capacity and skills to deliver high-quality, sustainable care.
• Staff reported that they felt that they worked well together as a team, and were well supported by senior managers.

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

• Fully implement revised processes to ensure that ‘Do Not Attempt Cardio Pulmonary Resuscitation’ documentation is stored in the patient record.
• Improve processes for the assessment of incoming medicines safety alerts and updates to ensure that these have been correctly assessed and implemented.
• Improve the process for monitoring of patients with long-term conditions to ensure blood tests are undertaken according to required timeframes.
• Fully establish the immunity status of staff in line with national guidance.

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