York Street Health Practice

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Staff reviewed assessments taking account of people’s communication, personal and specific health needs. The practice had designed bespoke new patient templates to support full assessments of health and care needs for the inclusion-health population.

Staff worked with all agencies involved in people’s care for the best outcomes, and to ensure smooth transitions; this was evidenced by numerous care plans demonstrating how the provider had overcome barriers to patients accessing the care and treatment they required.

Staff made sure people understood their care and treatment to enable them to give informed consent. Where concerns were highlighted, we saw evidence of mental capacity assessments, in conjunction with other organisations, to make Best Interest decisions.

This service scored 83 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them.

The provider had designed bespoke new patient templates to support a full assessment of health and care needs. The templates considered factors such as ethnicity, health beliefs and conditions, risks and experiences of trauma. This supported staff to offer the most appropriate care and treatment.

A dedicated team provided support to migrant families with NHS registration and new patient health checks. The practice often worked with entire family groups in order to ensure a full assessment could be carried out for each family member at one time.

The practice provided both healthcare and substance misuse services. This enabled assessments to take place to identify physical health, mental health, substance misuse and wellbeing needs and care plans developed to support individual needs.

We saw examples of individualised care plans which demonstrated how the practice had worked with patients and other providers to overcome barriers, and to ensure that patients had access to the care and treatment they required.

The practice could demonstrate how they used mental capacity assessments, in conjunction with other organisations, to make Best Interest decisions to support appropriate care outcomes, for example hospital admission.

People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. For example, results from the National GP Patient Survey (2025) confirmed that 90% of respondents were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment (national average 91%).

Reception staff were responsive to the needs of the local community. Staff told us that due to the patient population, they checked clinical records in full when communicating with patients to ensure all health requirements were managed during one contact. This was due to many patients not having regular access to telephones and a registered address; therefore, staff had to be proactive to ensure patients healthcare needs were met opportunistically.

Patients could be supported and referred to wider wellbeing services including mentoring, advocacy, housing, welfare, employability and social prescribing.

The practice planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance.

The provider had systems in place to review and monitor clinical practice against national standards. As part of our assessment, we reviewed an audit of Tuberculosis (testing and onward referral) in asylum seekers and refugees registered at York Street Health Practice against relevant standards.

The practice used an automated electronic recall system to support long term conditions reviews and other recalls such as shared care, repeat and follow up blood tests.

As part of our assessment, a CQC GP Specialist Advisor (SpA) carried out a series of remote clinical searches of patient records to assess the practice’s processes around the management of patients with long-term conditions. Overall, we found the practice had good management of these patients.

Due to the unique demographics of the patient population, disease prevalence differs from national prevalence. However, we noted that the provider took proactive steps to diagnose and treat patients with a long-term condition. For example, they had taken steps to address high rates of respiratory health conditions and lung disease in people experiencing homelessness (due to high rates of smoking and use of illicit substances), and address a lack of attendance for spirometry testing, by the introduction of an outreach spirometry service across the West Yorkshire area. This reduced barriers by taking services to people across the area and highlighted the need for more flexible services in order to diagnose and support vulnerable patient cohorts to improve health outcomes. In order to support this project staff within the service completed specific training in spirometry triage and delivered this in multiple locations including hostels and food banks, as well as on the Bevan Bus. At the time of our assessment, the spirometry outreach service had successfully engaged with 28 patients to carry out assessments since June 2025, along with 36spirometry tests within a clinical setting. Many of these patients had previously failed to engage with attempts to carry out assessment within a clinical setting.

The practice always worked well across teams and services to support people. They shared thorough assessments of people’s needs via multidisciplinary team meetings, involving other services and departments which were best placed to meet the needs of individuals. Information was shared between services via the clinical system, individualised care plans and joint working.

We saw numerous examples of effective joint working including:

Syphilis and Gonorrhoea Project in response to an outbreak among female street-based sex workers. The practice worked alongside the UK Health Security Agency to develop a doxycycline pre-exposure prophylaxis (PrEP) service (to promote the use of antibiotic doxycycline to prevent sexually transmitted diseases by taking within 72 hours after unprotected sex). This included launching an early meningitis vaccination programme in Leeds. The project was delivered in co-ordination with other organisations including drug and alcohol services and sexual health teams.

The practice worked in collaboration with Women Friendly Leeds and Gough and Kelly Security to support the Women’s Night Safe Space project. Clinical staff from the practice provided health support to women on Saturday evenings.

Due to the specific patient population, and the need to better support patients with addiction, the practice hosted Forward Leeds (drug and alcohol service) recovery co-ordinators. GPs at the practice had undertaken specific Royal College of General Practitioners (RCGP) substance misuse certification to provide and manage prescribing and offer a collaborative model of care for patients receiving support and treatment for addiction.

The practice had worked with Leeds GATE (Gypsy and Traveller Exchange) to attend the local horse fair and were offered health checks to over 40 people within the community, some of which were signposted to their GP, all were made aware of the services available via York Street Health Practice.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. The practice supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff focussed on identifying risks to patients’ health, including patients at risk of developing a long-term condition and those with additional support needs such as addiction services or support with accommodation. Staff supported national priorities and initiatives to improve population health.

The practice was co-located with St Anne’s Community Services (a charitable organisation which provides support for people who are homeless and people with mental health or addiction issues) and provided a drop-in service to ensure people had access to health care services. The practice also worked alongside other organisations to provide food support, drug and alcohol services, housing and benefits advice, opticians, dental care and a barber service.

Staff from the practice were working in conjunction with Getting Clean (a local mutual aid organisation) on a 12-month pilot project of offer peer-led outreach across the city. This provided a face to face outreach service, to build relationships with local communities and improve access to support.

The practice routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Due to the specific cohorts of patients, childhood immunisation rates did not meet expected uptake or World Health Organisation (WHO) targets in all areas. For example, 71.4% of children aged 5 had received immunisation for measles, mumps and rubella (expected 80%, WHO target 95%). We noted that children within the immunisation age range registered at the practice was very low. For example, 7 children were aged between 2 and 5 years and 11 aged 1. We discussed childhood immunisation uptake with the provider as part of this assessment and were advised that low reported uptake was due to the high turnover of patients at the practice, which included children within immunisation age ranges, many of whom were new to the country.

The practice offered a full ‘catch up’ vaccination schedule for everyone who registers at the practice, regardless of age to ensure vaccination coverage was as effective as possible in both children and adults. However, often this was outside of recommended vaccination schedules, therefore was not included in the practice figures.

To encourage uptake of vaccinations across the migrant population, the practice had undertaken work to identify the barriers and taken steps to overcome these. This included distribution of translated leaflets and posters in migrant hotels, and upskilling staff in vaccination counselling for newly arrived migrants.

Verified data published by NHS England indicated that the practice had not achieved expected uptake for cervical screening. For example, 47.2% of people aged 25 to 49 had received an adequate screening test within the last 3.5 years (expected 80%) and 50% of people aged 50 to 64 had received an adequate screening test within the last 5.5 years (expected 80%). However, we reviewed unverified data provided by the practice which indicated 99% of people aged 25 to 49 had received screening and 96% of people aged 50 to 64 had received screening.

The practice told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.