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Dr R D Gilmore and Partners Good


Review carried out on 9 September 2021

During a monthly review of our data

We carried out a review of the data available to us about Dr R D Gilmore and Partners on 9 September 2021. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Dr R D Gilmore and Partners, you can give feedback on this service.

Inspection carried out on 26 May 2021

During an inspection looking at part of the service

We carried out an announced review of Dr R D Gilmore and Partners on 26 May 2021. Overall, the practice is rated as Good.

Dr R D Gilmore was inspected on 15 March 2018 and rated as good overall, and requires improvement for providing well led services. A follow up inspection 8 November 2018, rated the practice as good for providing well led services and the practice remained good overall. However, the practice was rated as requires improvement for providing services to people within the population group of long-term conditions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr R D Gilmore and Partners on our website at

Why we carried out this review.

This was a follow-up review of concerns identified during the last inspection in November 2018.

The focus of this review was:

  • To review the services provided to people with long-term conditions and the outcomes for these patients using Quality and Outcomes Framework (QOF) performance.

How we carried out the inspection/review

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 reviews differently.

This review was carried out off site. This was with consent from the provider and in line with all data protection and information governance requirements.

Our approach included:

  • Conducting staff interviews via tele-conference.
  • Reviewing performance data available at the time of our inspection.

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.

This practice remains rated as good overall. Following this focused review, we have rated the practice as good for providing care for the population group, long-term conditions.

We found that:

  • For those patients with long-term conditions; their needs were risk assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
  • The practice continually reviewed and adjusted how it delivered services to meet the needs of patients with long-term conditions during the COVID-19 pandemic. Patients could access care and treatment in a timely way. Outcomes for patients with long-term conditions were comparable to local clinical commissioning group (CCG) and national averages.
  • Throughout the pandemic, patients with long-term conditions were recalled as appropriate. Patients were proactively contacted using text messages and latterly were contacted personally by healthcare assistants (HCAs) as the practice noted a positive response to this. Clinicians opportunistically used all patient contacts to carry out reviews.
  • Face-to-face appointments were offered when clinically necessary.
  • Focusing on healthy living principles, the practice worked in a multidisciplinary manner to ensure that patient needs were met. Working collaboratively with their local Primary Care Network (PCN) and utilising digital technologies, patients could access appointments with occupational therapists, social prescribers, dieticians and domestic violence workers. We were given an example of where, when safeguarding concerns were highlighted with a patient, a multi-disciplinary video conference was convened with relevant professionals within two hours.

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

  • Continue to closely monitor personalised care adjustments for patients with diabetes.

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

Review carried out on 23 October 2019

During an annual regulatory review

We reviewed the information available to us about Dr R D Gilmore and Partners on 23 October 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 08 Nov to 08 Nov 2018

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Dr R D Gilmore and Partners on 15 March 2018. The overall rating for the practice was good, with a rating of requires improvement for providing well led services. The full comprehensive report on the March 2018 inspection can be found by selecting the ‘all reports’ link for Dr R D Gilmore and Partners on our website at


In addition to the areas for improvement identified under the key question of providing well led services, we also identified areas for improvement for providing effective services for the population group people with long term conditions. We said the practice should consider improving the following areas:

  • Review and improve systems for Quality and Outcomes Framework (QOF) patient recalls.

This inspection was an announced focused inspection carried out on 8 November 2018 to review the improvements made by the practice following our previous inspection in March 2015.

At this inspection we found:

  • The practice had signed up to the Productive General Practice quick start programme to review their QOF recall processes. This involved clinical and non-clinical staff to get a good understanding of the process from start to finish. As a result of the review, the practice had agreed a common approach and implemented the new recall system in August. We saw a number of improvements to the recall system including:

  • Patients were recalled by month of birth, offering a single approach to booking appointments.
  • All necessary blood tests were carried out by health care assistant in preparation for review.
  • Patients with more complex symptoms of diabetes were booked in with lead diabetes nurse who was also an independent prescriber.

  • In addition, the practice was proactively trying to engage with patients during routine appointments to book reviews and additional nursing appointments had been allocated for reviews. However; the changes implemented had not been in place for long enough to demonstrate effective care for people with a long-term condition.

  • The practice had introduced a new system for management of complaints. All complaints were reviewed at the clinical meeting to ensure appropriate learning was identified and action implemented.

  • The practice was working with the NHS Leeds Clinical Commissioning Group to review capacity and demand planning in order to improve access for patients. This was a continuing area of focus for staff at the practice.

  • Following our inspection in March 2018, the practice had introduced local leadership via a front-line services manager to improve communication and support for staff.

  • The practice had commissioned an independent staff engagement survey to obtain feedback and address issues raised by staff.

The area where the practice should make improvements are:

  • Continue to monitor and improve performance against Quality and Outcomes Framework performance for patients with long-term conditions.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection carried out on 15 March 2018

During a routine inspection

This practice is rated as Good overall. (Previous inspection March 2016 – Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Requires Improvement

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Dr R D Gilmore and Partners on 15 March 2018. We carried out this inspection as part of our inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice had good systems in place to safeguard children and adults from abuse and were proactive in working with other organisations.
  • The practice ensured that care and treatment was delivered according to evidence- based guidelines.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Review and improve systems and processes to assure themselves that action is taken as a result of all complaints and relevant learning is shared.
  • Continue to work to address any issues identified as a result of their management and support services being transferred.
  • Review and improve systems for Quality and Outcomes Framework patient recalls.
  • Engage with staff to provide effective communication and work to address any concerns.
  • Engage with patients to improve satisfaction rates.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 16th March, 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Manor Park Surgery on 16th March, 2016.  Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows.

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.Risks to patients were assessed and well managed, through the Risk and Governance Assurance Framework.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.  Information was provided to patients to help them understand the care available to them.
  • Information about services and how to complain was available and easy to understand and improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it reasonably easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of, and complied with the requirements of the duty of candour.
  • The practice used innovative and proactive methods to improve patient outcomes and worked with other local providers to share best practice. For example, weekend appointments via the ‘Hub’ which covered five practices. They also shared management staff and expertise with a neighbouring practice.

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group.
  • The practice had a clear vision which had quality and safety as its top priorities and was understood by staff.
  • The practice had strong and visible clinical and managerial leadership and governance arrangements.

We saw several areas of outstanding practice:

  • The practice had arrangements in place that assured seven day access to primary medical care and 24 hour access to medical advice.

  • Physiotherapy First.  An in-house physiotherapy team, operated from purpose built rooms and the physiotherapy team had full access to the electronic patient records. Patients could be seen the same day and they could directly refer themselves into this service.  A review of 115 patients showed that 100% would recommend the service to friends and family.

  • The Patient Participation Group ran an education service for young patients. This was developed in response to public health data which showed educational attainment in the Bramley area was 10% below the national average, and 20% below the national average in maths.  It was run on a voluntary basis by members of the PPG with support from the practice and Leeds City Council and created a focus for health engagement and education within the younger community and their parents and carers registered with the practice, to stimulate learning.

  • The practice employed an advanced nurse practitioner to focus on the 2% of the patient population identified as likely to be admitted to hospital as an emergency admission.  Evidence showed that emergency hospital admissions for this group of patients had been reduced from 0.9 per 100 patients to nil over the 32 weeks prior to the CQC inspection.

The areas where the provider should make improvement are:

  • Consider including in the complaints annual review information about timeliness and appropriateness.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 30 September 2014

During an inspection looking at part of the service

Our inspection of this practice on 17 December 2013 found that the systems in place for reducing the risks associated with the spread of infections was not robust. We inspected on the 30 September 2014 to check whether changes had been made to ensure that these risks were minimised.

We found that there were now effective arrangements in place to reduce these risks.

Inspection carried out on 17 December 2013

During a routine inspection

We spoke with six patients who were visiting the practice They were complimentary about the practice and the staff. One told us the staff were, �Always courteous and respectful.� Others described the practice as �Very good� and the receptionists �Polite and helpful�. One patient told us they had a, �Brilliant experience today.�

Patients understood the care and treatment choices available to them. Health advice and information leaflets were available in the practice entrance and waiting areas. One notice board was reserved for the Patent Participation Group.

The patients we spoke with had not experienced any difficulty in obtaining an appointment at the practice. They told us they had seen an improvement in the appointments system. One patient said being able to telephone and speak to a doctor was �Really helpful.�

The consulting and treatment rooms were visibly clean. However the standard of cleaning in the patient toilets was poor. Cleaning equipment had not been used or stored correctly. The practice was unable to provide assurance that cleaning and infection control procedures were effective.

The staff told us they felt, �Very well supported�. They spoke positively about the practice and their colleagues and one said, �I love my job.�

The practice had supported the establishment of a Patient Participation Group. The group felt well supported by the practice. They said their comments were listened to and their suggestions acted upon. The group had worked with the practice to improve the appointments system.