Shakespeare Medical Practice

Updated 22 May 2023

Shakespeare Medical Practice is located at Burmantofts Health Centre, Cromwell Mount, Leeds LS9 7TA, which is approximately 2 miles East of Leeds city centre. The premises are leased from Leeds Community Health Trust, which is responsible for the maintenance of the building. There are a variety of community health services and another GP practice co-located within Burmantofts Health Centre. There is disabled access to the building and an onsite car park. All services are on the ground floor.

From this location, the provider, One Medical Group, has a General Medical Services (GMS) contract to provide GP services to a registered patient population of 7,056. The provider holds a separate contract with Leeds Teaching Hospitals Trust (LTHT) to provide a walk-in service (WIC). The WIC is accessible to all patients including those not registered with a GP practice. This inspection included both the GP practice and the WIC.

One Medical Group (trading as One Medicare Limited) operates 16 sites across the UK, ranging from registered GP practices, walk-in centres and urgent care centres. The provider’s head office and operations centre is based in Leeds, West Yorkshire.

The provider at this location is registered with CQC to deliver the regulated activities of diagnostic and screening procedures, maternity and midwifery services, treatment of disease, disorder or injury, family planning and surgical procedures.

The services from this location are situated within the NHS West Yorkshire Integrated Care Board area.

The GP practice is open between 8am and 6.30pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments. Patients have access to extended hours appointments at evenings and weekends at a hub based in Leeds, which is organised by the local confederation. When the GP practice is closed out-of-hours services are provided by Local Care Direct, which can be accessed by calling the NHS 111 service.

The WIC is open 7 days a week between the hours of 8am and 8pm. This includes Bank Holiday periods.

The GP practice consists of a male clinical lead GP and 5 salaried GPs (4 male and 1 female), a practice nurse, a healthcare assistant and a health coach. The clinical team is supported by a Practice Manager and 4 reception/administrative staff. The practice had pharmacy support and a social prescriber through the primary care network (PCN).

The WIC consists of 2 advanced clinical practitioners (1 male and 1 female), 2 triage nurses (1 male and 1 female). At the time of our inspection locum clinical staff were regularly used to support the service. The clinical staff are supported by 4 patient navigators and a dedicated urgent care management team.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the first lowest decile (on a scale of 1 to 10, decile 1 represents the highest levels of deprivation and decile ten the lowest). According to the latest available data, the ethnic make-up of the practice area is 57% White, 16% Asian, 16% Black, 6% Mixed, and 5% Other.

Updated 22 May 2023

We carried out an announced onsite comprehensive inspection at Shakespeare Medical Practice on 16 March 2023. Prior to the onsite inspection, a GP specialist advisor conducted a remote clinical notes search on 7 March 2023.

Following this inspection, we rated the service as requires improvement overall.

Safe - good

Effective – requires improvement

Caring - good

Responsive - good

Well-led - requires improvement

The service was last inspected on 20 December 2017 and rated good overall and good for all key lines of enquiry. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Shakespeare Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this comprehensive inspection to follow up concerns reported to us.

How we carried out the inspection

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 using video conferencing.
• Reviewing staff questionnaires.
• 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 shorter 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:

• There were systems in place to safeguard children and vulnerable adults from abuse and staff knew how to identify and report safeguarding concerns.
• 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.
• There were gaps in systems and processes to support good governance at the walk-in centre which included the management of complaints, the locum induction process, clinical supervision, and staff communication.

We found breaches of regulation. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Establish effective systems and processes to ensure staff receive appropriate support and supervision as necessary to enable them to carry out the duties they are employed to perform.

In addition, the provider should:

• Summarise any outstanding patient records to ensure that all information is available for the delivery of safe patient care and treatment.
• Review and update training records for staff to demonstrate they have completed all required training.
• Continue to recruit patients to join the Patient Participation Group to establish a group representative of the practice population.
• Review and improve the system for access to management support for staff working within the walk-in centre.
• Review the whistleblowing policy and include signposting to external agencies in line with the Freedom to Speak Up Policy for the NHS.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services