Burley Park Medical Centre

Updated 13 December 2021

Burley Park Medical Centre is located in Leeds at:

273 Burley Road,

Leeds,

LS4 2EL.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury, family planning and surgical procedures.

The practice is situated within the NHS Leeds Clinical Commissioning Group (CCG).

The practice provides services to a patient population of approximately 12,738 patients under the terms of a locally agreed NHS Personal Medical Services (PMS) contract.

The practice is part of a wider Primary Care Network (PCN) of seven GP practices which works closely with a second PCN comprising of three local GP practices. A PCN is a group of practices who work together to focus and improve local patient care and provide care closer to patients’ homes. This PCNs also work closely with other PCNs who together form the Leeds GP Confederation, a not for profit social enterprise, working together to improve the health of the people of Leeds, by strengthening and sustaining primary care.

Information published by Public Health England shows that deprivation within the practice population group is in the fourth most deprived decile. The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 78.5% white, 11.5% Asian, 3.8% Black, 4% mixed, and 2.2% of other ethnicities. Up to 40% of patients, and 50% of the new patients who registered with the practice in the last year did not have English as their first language.

The patient population is not comparable to CCG or national averages; approximately 54% of registered patients are aged between 20 and 39.

There are also lower than CCG and national average numbers of older people and children aged 19 and under, registered with the practice. Patient turnover at the practice is approximately 30% each year.

There is a team of four GP partners (three of whom are male, and one is female) and four salaried doctors (all of whom are female). There are also three advanced nurse practitioners, (ANPs) who are female. The practice has a team of three nurses and a healthcare assistant (HCA), who provide support to patients and nurse-led clinics for long-term conditions. The clinical team are supported at the practice by an experienced team of reception and administration staff. The newly appointed practice manager and assistant practice manager, provide managerial oversight.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, the practice continued to offer a range of appointment types. At the time of our inspection up to 70% of appointments each week were face to face, with online econsultations and telephone consultations also available.

Extended access is provided locally by the Leeds GP Confederation, where late evening and weekend appointments are available from 21 hubs across the city, including Burley Park Medical Practice. The service operates Monday to Friday 6.30pm to 8pm and Saturday and Sunday 9am to 1pm. Out of hours services are provided by Local Care Direct.

Updated 13 December 2021

We carried out an announced inspection at Burley Park Medical Centre on 16 and 17 November 2021. Overall, the practice is rated as Good.

The ratings for each key question are:

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

Following our previous inspection on 10 December 2015, the practice was rated good overall and for all key questions, except for providing responsive care which was rated as outstanding. At this inspection we rated the practice as good for providing responsive services. We did not see a deterioration in standards at this inspection, but many of the initiatives which the practice undertook in December 2015 are now widely recognised as good practice and in place across the clinical commissioning group and nationally.

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

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 telephone and 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 site visit which included face to face interviews with staff.

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 overall and for all key questions.

We found that:

• The support offered by the team to two local care homes was described by the home managers as exceptionally positive. Weekly reviews of the residents’ needs were carried out and visits made on request throughout the COVID-19 pandemic. The team was described as offering respectful, kind and safe care.
• The practice was experienced in offering Gender Dysphoria services to patients. Regular searches were run to identify patients who may be in need of support. When gender specific cancer screening services were indicated, each patient was individually contacted by an experienced clinician to offer guidance and support.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. The team reviewed their appointment system in April 2021 and when an appointment was needed, patients were given the choice of a telephone or face to face appointment at each contact. Face to face consultations were conducted when this was clinically necessary.
• Patients could book these appointments on the day or in advance. Urgent appointments were available every day for those with enhanced needs and complex medical issues. At the time of our inspection between 60 to 70% of the appointments offered at the practice were face to face.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• Staff told us that leaders were consistently supportive, helpful, knowledgeable and approachable at all times. Leaders at the practice told us this support was mutual.

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

• Continue with newly implemented plans to review and retain overall responsibility for individual independent non-medical prescribers to ensure that they have the necessary skills and knowledge to carry out the role.
• Continue with agreed plans to review historical safety alerts, to reduce the potential for error with patients who take a combination of medicines which may interact with each other.
• Review the management of complaints and significant events to ensure that outcomes, learning and changes made following the recording of these issues are documented and shared with the staff team.
• Continue to review and embed changes made to the use of the clinical records system, to ensure that patients’ recalls and additional interventions, such as the need to undertake reviews and monitoring, are responded to in a timely manner.
• Take action to ensure evidence of Disclosure and Barring Service (DBS) checks for all members of the team is documented.
• Continue to update the level of safeguarding training undertaken by non-clinical staff.

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