Archived: Shadwell Medical Centre

Updated 3 March 2023

Shadwell Medical Centre is located at:

137 Shadwell Lane

Leeds
West Yorkshire

LS17 8AE

The service is provided by Central North Leeds Primary Care Network (PCN), who are registered with the CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.

PCNs are a group of practices working together to focus care on the needs of the local population.

Shadwell Medical Centre operates from a purpose built, single storey building. There is onsite parking and a co-located pharmacy and opticians.

The practice is situated within the West Yorkshire Integrated Care Board (ICB) area and provides services to 4,232 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.

Information published by the Office for Health Improvement and Disparities, rates the level of deprivation within the practice population as 10, on a scale of 1 to 10. Level 1 represents the highest levels of deprivation and level 10 the lowest.

According to the latest available data, the ethnic make-up of the practice area is 81% White, 14% Asian and 5% originating from black, mixed or other non-white ethnic groups.

Care at the practice is provided by 1 salaried GP, 7 long-term locum GPs, 2 practice nurses, a health care assistant and a phlebotomist. The clinical team is supported by a practice manager, an office manager and an administrative team.

The practice team are supported by Central North Leeds Primary Care Network who are responsible for areas including clinical leadership and human resources.

The practice is open from 8am until 6pm Monday to Friday. The practice offers a range of appointment types including book on the day and telephone consultations.

In addition, the practice offers in-house extended hours appointments from 7.30am on Tuesday and Thursday mornings.

Patients can also access a variety of weekend appointments at a local practice via the extended access hub. This service is available from 9am until 12pm on Saturday and Sunday.

Updated 3 March 2023

We carried out an announced comprehensive inspection at Shadwell Medical Centre on 27 January and 10 February 2023. Overall, the practice is rated as good.

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. This was the first inspection of this provider since they registered with the Care Quality Commission.

How we carried out the inspection/review

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 facilities.
• Staff questionnaires sent to staff ahead of the inspection.
• Speaking with patients by telephone.
• 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 provider had made significant improvements to the service since taking over responsibility of the contract.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Staff were clear about their roles and felt supported by leaders and managers.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• 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.

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

• Continue to work to improve the uptake of childhood immunisations.
• Improve documentation of high risk drug monitoring so that information is clearly accessible in patient records.
• Improve documentation relating to action taken as a result of safety alerts.
• Improve the process for medication reviews so that all reviews are of good quality and cover all required areas.
• Continue to monitor and improve patient satisfaction.
• Improve processes to identify patients with a learning disability.
• Take action to improve the process of recording which patients are also carers.