York Street Health Practice

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The practice had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly and learning was shared with the practice team. The practice had robust systems in place to keep people safe, this included capturing all healthcare needs at the point of registration via in-depth health checks, working with other services to support vulnerable groups including those not registered with the practice, and ensuring information recorded regarding patients was accurate. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks were mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training to maintain high-quality care. We saw evidence of individualised plans to support safe prescribing, staff managed medicines well and involved people in planning any changes.

This service scored 88 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There was a dedicated policy and procedure to support people to report incidents or concerns. The policy referred to ‘learning events’ to encourage a low-threshold for reporting and to promote a no-blame culture.

Staff we spoke with and received feedback from felt supported to report learning events and were clear on the process to do so. Staff told us that any concerns would be listened to and acted upon by managers and leaders.

All learning events recorded were discussed at bi-weekly meetings. Lessons learned were discussed at whole team meetings and circulated in regular staff newsletters.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The practice always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

There were robust systems in place for processing information relating to new patients. The provider had developed new patient health check templates to meet the specific needs of the patient demographic. For example, there were questions concerning housing status, trauma screening, depression and anxiety screening tools. The templates included links to initiate tasks to other members of the clinical team for further follow up and additional templates such as blood borne virus (BBV) screening. This enabled the team to capture all relevant information at the point of registration. Leaders at the practice told us how the templates had been seen as exemplars and were used nationally across the country.

There was a dedicated migrant health team who supported patients with NHS registration by creating new NHS profiles and ensured personal information such as name and date of birth, was recorded correctly. The practice also worked closely with Primary Care Support England (PCSE) to ensure duplicate records containing incorrect information were eradicated.

The practice worked with stakeholders and other agencies to ensure continuity of care. We reviewed numerous case studies which outlined how the practice had worked with services such as paramedics, housing services, and drug and alcohol services. This demonstrated how intervention teams working within York Street Health Practice had worked to improve both physical and social aspects for service users.

The practice worked with Leeds Community Healthcare to support people experiencing homelessness under the Hospital In-Reach Team. This service provided 20 beds within the community for ongoing support upon discharge from hospital. The practice provided a team of 2 GPs to carry out visits and ongoing care and treatment to reduce the risk of readmission.

There was a system in place to ensure referrals and test results were managed in a timely manner and that referrals, including urgent cancer referrals, were subject to regular monitoring.

We heard examples of how patients had been accompanied by a clinical member of the team to attend appointments with other services such as hospital and dental.

The practice had well established systems in place to identify, record and act upon concerns. During our assessment we saw evidence that staff and leaders treated safeguarding as a priority.

There were dedicated GP leads for safeguarding adults and children. All the staff we spoke with or received feedback from knew who the lead was and what steps they should take if they had any concerns. Many were able to provide examples of when concerns had been identified. The practice held regular multidisciplinary team meetings to discuss cases, coordinate referrals and ensure continuity of care. We were able to review case studies which demonstrated how the provider had worked to support patients at risk of or suffering from abuse. Interventions included securing temporary accommodation, prescribing to support withdrawal from illicit substances and Best Interest Decisions to support appropriate care provision.

The safeguarding leads formed part of the wider Safeguarding Improvement Group. This group consisted of all safeguarding leads across the provider organisation and met quarterly to discuss topics including training requirements and compliance, safeguarding audits, recent learning and changes to practice.

The practice monitored adherence to safeguarding legislation by undertaking an annual audit which had been developed by NHS West Yorkshire Integrated Care Board (ICB). The audit conducted in May 2024 demonstrated the practice was fully compliant in all areas. A further audit was conducted in August 2025 when the practice identified 2 areas around training for further action. We saw this action had been undertaken as part of this assessment.

Records demonstrated that staff had completed safeguarding adults and children training to the appropriate level.

Staff had also completed initial training to support interactions with patients with a learning disability or autism. We were advised that further training would be undertaken when this was available.

The practice utilised the safeguarding node on the clinical system to identify vulnerable patients. Information stored within the safeguarding node was then available for other teams and organisations involved in the patients’ care.

The practice held a record of all patients at risk of or suffering from abuse. These patients were discussed in individual multidisciplinary meetings. In addition, safeguarding concerns were discussed at whole team meetings, as it was acknowledged that the patient services team had well-established relationships with patients and their input was invaluable.

The practice always worked well with people to fully understand and manage risks by thinking holistically. They provided care that fully met people’s needs and was safe and supportive.

The practice offered a variety of services to meet the needs of local population, in a setting in which they felt comfortable. This included an outreach vehicle, referred to as the Bevan Bus. The Bevan Bus hosted a dedicated team including a paramedic, nurses, an occupational therapist and a healthcare assistant. The aim of this service was to engage with people experiencing homelessness and vulnerable people who would otherwise fail to engage with healthcare services. The bus operated from 5am each morning around Leeds and looked for people sleeping on the streets or in tents to offer healthcare advice, support and treatment (under temporary registration with York Street Health Practice). The Bevan Bus staff looked to overcome barriers to engaging with health and care services, build relationships and encourage full registration for care at the practice. As part of our assessment, we reviewed numerous case studies demonstrating the impact of this service for patients. We saw that conditions such as leg ulcers, burns and addiction had been identified and addressed through this service.

The Bevan Bus also doubled as a women’s safe space on Friday evenings. This provided a space for any women feeling vulnerable, including sex workers, to have company, a warm drink and access to healthcare.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

We reviewed training records and saw that staff had completed basic life support training. All the staff we spoke with and received feedback from also confirmed they had attended the training.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

During our site visit, we observed the premises to be clean and well-maintained. At the time of our assessment the provider had recently completed a large refurbishment project to offer more clinical space and a dedicated quieter waiting area for more vulnerable patients.

Services were offered from a three-storey building; however, all patient areas were located on the ground floor.

Contracts were in place to ensure the premises were maintained, and appropriate risk assessments were in place. These were the responsibility of the building landlord, but we saw evidence that the provider had assurance processes in place.

There was a business continuity plan in place which was monitored and reviewed.

The practice made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Due to the complex nature of the patient population, the provider required all staff to undertake a 6-month training programme to ensure they were supported to understand the specific needs of patients.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately and staff were working within their agreed areas of competence.

We saw that staff had access to external supervision to support them within their roles. For example, 1 of the practice nurses had support from a psychologist for mentoring and advice.

There was a recruitment policy in place which outlined the necessary checks required during the recruitment process. We reviewed a sample of staff files during our site visit and found that the recruitment policy had been followed in all cases.

The practice assessed and managed the risk of infection. There was a dedicated infection prevention and control (IPC) lead, and all staff were aware of who this was and how to raise concerns.

Premises cleaning schedules were in place and followed. We reviewed records of monthly audits of cleaning levels, which were carried out by the director of the cleaning company to monitor compliance.

We saw that the immunisation status of staff was obtained at the point of recruitment in line with national requirements. Where staff members had not had appropriate vaccinations, they were referred to occupational health. We noted some staff members had declined vaccinations; however, the provider had completed appropriate risk assessments to reduce the risk of harm to the staff members and patients.

The practice routinely screened all new patients for viruses including chlamydia, HIV and hepatitis. In addition, all migrant patients were screened for tuberculosis (TB) screening.

The practice made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. There was a dedicated GP pharmacist who had oversight of prescribing processes and was available to provide support and guidance as required.

Prescribing was tailored to the needs of the patient population and considered safeguards such as short issue dispensing and access to medication across public holiday periods. The GP pharmacist worked closely with community pharmacies to ensure patients continued to access required medication. We saw how this had a positive impact on patients, including examples of how the GP pharmacist had shared their personal mobile number with community pharmacists to make themselves available and ensure ongoing support for patients outside of practice hours.

There were comprehensive processes to support prescribing of medication with addictive potential. Prescription durations were tailored to support individual needs, ranging from 1 to 56 days.

Staff within the practice were able to provide examples of how they proactively supported patients with access to medication. For example, those who were advised to take aspirin throughout pregnancy but were unsure of how to access the medication. We were able to review cases studies which demonstrated how the practice worked flexibly with patients to optimise adherence with prescribed medicines. Examples included flexible prescribing, liaison with community pharmacy and the use of dosette boxes.

As part of this assessment, a Care Quality Commission (CQC) GP Specialist Advisor (SpA) conducted a series of remote clinical searches of patients records to assess the practice’s procedures around prescribing and medicines management. We found that there were processes in place for monitoring patients prescribed direct oral anticoagulants (DOACs). We noted that in some cases, monitoring had been undertaken by secondary care and had not been clearly referenced on the patient record. We raised this with the provider as part of this assessment.

We reviewed the systems and processes in place to receive, disseminate and act upon patient safety alerts. Overall, the findings of our clinical search indicated a structured approach.

Medication reviews were found to be well documented and contained appropriate information. Due to the patient population, reviews were carried out regularly at periods between 3 and 6 months.

There was a programme of regular clinical audits of prescribing that focused on safe usage and improving care and treatment.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs.

Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.