The Care Quality Commission
  • Doctor
  • GP practice

Kirkstall Lane Medical Centre

Overall: Good read more about inspection ratings

216 Kirkstall Lane, Leeds, West Yorkshire, LS6 3DS (0113) 295 3666

Provided and run by:
Kirkstall Lane Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Kirkstall Lane Medical Centre on 6 July 2023. 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 Kirkstall Lane Medical Centre, you can give feedback on this service.

16 June 2022

During a routine inspection

We carried out an announced comprehensive inspection at Kirkstall Lane Medical Centre on 15 and 16 June 2022. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive – Good

Well-led - Good

The practice was previously inspected on 10 March 2016 and was rated outstanding overall and for providing responsive and well-led services.

At this inspection we noted that areas previously regarding as outstanding practice were now embedded within other GP practices. While the provider maintained many of these good practices, the threshold to achieve an outstanding rating had not been reached. The practice is therefore now rated good for providing responsive and well-led services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Kirkstall Lane Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.

How we carried out the inspection

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 inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit
  • Staff questionnaires sent to staff ahead of the 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.

We have rated this practice as Good

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • The practice had good systems in place to identify and support patients at risk of or suffering from abuse. Staff worked regularly with other stakeholders such as health visitors and palliative care nurses to support those patients.
  • 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.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The practice responded to feedback from patients and staff regarding access to services and tailored the appointment system to best meet the needs of the patient population.
  • All staff felt supported by the manager and GP partners. They reported Kirkstall Lane Medical Centre to be a good place to work.

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

  • Maintain a record of safety alerts relevant to the practice and action taken as a result of these.
  • Improve systems for sharing learning from significant events to ensure all staff are included in this process.
  • Implement processes for checking registration with professional bodies such as Nursing and Midwifery Council to ensure all staff have renewed registration.
  • Continue to take steps to identify registered patients who are also carrying out the role of a carer.
  • Improve uptake of cervical screening.

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

10th March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kirkstall Lane Medical Centre on 10th March, 2016. Overall the practice is rated as outstanding.

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

  • There was an open and transparent approach to safety and a robust and effective system in place for reporting and recording significant events.
  • The provider was aware of and complied with the requirements of the Duty of Candour.
  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice for example the Care Home project.
  • Feedback from patients about their care was consistently and strongly positive.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs.  For example they worked with the local charity that provided accommodation for people who had been involved in people trafficking and human rights abuses.
  • The practice implemented suggestions for improvement and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group. Examples of this were, the changes made to the services provided to mothers and their children after consultation, and the extended hours service of 7am-7pm daily and input into the ‘Hub’ arrangements.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. Information about services and how to complain was available and easy to understand
  • The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders, was prominently displayed in the waiting room and was regularly reviewed and discussed with staff.
  • There was a clear leadership structure with devolved responsibility and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

We saw several areas of outstanding practice including:

  • The practice provided a same day service, when needed, for patients who are survivors of human rights abuses and extended appointments were available to support the use of the interpreter services.  There was a lead GP identified for this group of patients,who had made contact with other providers of services to this group, and who had visited the residences to gain a broader understanding of the care that was needed.  This had resulted in the delivery of a need and evidence based, targeted service for this particular group of vulnerable patients.
  • The practice had developed and implemented a ‘dispersed management’ model which devolved power and empowered staff to make decisions and change working practices. This had resulted in staff feeling valued, motivated and involved in the practice.  It also meant that improvements and changes were implemented promptly.
  • The lead GP for care homes had a dedicated weekly session to proactively review care home patients and spend focussed time agreeing with each person (and their families) preferred approaches to their care and ensured this was documented and agreed with care home staff.
  • A protocol that helped practice staff to recognise and assist carers had been developed by the practice.This ensured that carers were routinely checked and offered support.

However there were areas of practice where the provider should make improvements:

  • Recording and updating of Hep B status for all members of clinical staff.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice