Background to this inspection
Updated
20 May 2021
The Windmill Health Centre is located at Mill Green View, Leeds, West Yorkshire, LS14 5JS. This location was visited as part of the inspection. The practice provides services for approximately 8,400 patients under the terms of a Personal Medical Services (PMS) contract. The practice buildings are accessible for those with a physical disability or mobility issues. In addition, the practice has on-site parking available for patients, with designated spaces for disabled patients who require them. The practice is due to locate to a new purpose-built location in August 2021.
The practice is part of a wider network of GP practices operating as Seacroft Primary Care Network.
The Windmill Health Centre is registered with the Care Quality Commission to provide the following regulated activities; surgical procedures, diagnostic and screening procedures, family planning, maternity and midwifery services and the treatment of disease, disorder or injury.
Information published by Public Health England reports deprivation within the practice population group as one on a scale of one to 10. Level one represents the highest levels of deprivation and level 10 the lowest. The National General Practice Profile states that approximately 94% of the practice population is from a White British background.
The average life expectancy of the practice population is lower than the national average for both males and females (76.2 years for males, compared to the national average of 79 years and 81.3 years for females, compared to the national average of 83 years.)
The age distribution of the practice population shows that the practice has slightly more younger patients (0-14 years) than local and national averages. There are more female patients registered at the practice compared to males.
The clinical team consists of six GP partners (three male/ three female), one salaried GP (female), one Advanced Care Practitioner (female), three practice nurses (female) and four health care assistants (female). The provider is also an accredited training practice. The clinical team is supported by a practice manager and a team of administrative and management support staff. Allied with the practice is a team of community health professionals that includes health visitors, community matrons, midwives, members of the district nursing team and pharmacy professionals.
The practice offers:
- Telephone triage
- Pre-bookable appointments
- Urgent and on the day appointments
- Face to face
- Telephone and video consultations
- Home visits
Appointments can be made online or by telephone.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments are telephone consultations. Face to face appointments are still available at this time when required.
Practice opening times are:
- Monday - 8am to 6pm
- Tuesday – 7am to 6pm
- Wednesday – 7am to 6pm or 8am to 6pm on alternate weeks
- Thursday – 8am to 6pm
- Friday – 8am to 6pm
Extended hours access is provided locally by Seacroft Primary Care Network operating from Oakwood Lane Medical Practice, 2 Amberton Terrace, Leeds, West Yorkshire LS8 3BZ. Out of hours services are provided by Local Care Direct Limited.
Updated
20 May 2021
We carried out an announced focused follow-up inspection at Windmill Health Centre on 6 May 2021. Overall, the practice is rated as good.
Safe - Good
Effective – only inspected the population group Families children and young people – Good
Caring – Not inspected or rated
Responsive – Not inspected or rated
Well-led - Not inspected or rated
The ratings for Caring, Responsive and Well-led have been carried forward from the previous inspection in May 2019 and remain good.
Following our inspection on 30 May 2019, the practice was rated good overall and as requires improvement for the provision of safe services. In addition, we rated all population groups as good except for Families, children and young people which we rated requires improvement for providing effective services. We issued a Requirement Notice for a breach of Regulation 15(1) Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Premises and Equipment.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Windmill Health Centre on our website at www.cqc.org.uk
Why we carried out this inspection
This was a focused inspection to follow up on concerns and issues identified at the last inspection, these included:
- The physical condition of the consultation and treatment rooms was below the required standard. The provider had put in place an action plan to improve these rooms, but at the time of the last inspection this work had not been completed.
- Child immunisation performance was below the minimum target of 90%.
- The provider was not fully assured that staff immunity status checks had been carried out in relation to measles, mumps and rubella, and varicella.
- The provider had a small backlog of patient correspondence which needed scanning and placing on the patient record.
- Cancer review performance in relation to the number of cancer reviews carried out with patients within six months of diagnosis was below local and national averages.
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:
- Requesting evidence and information from the provider.
- A short 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.
We found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- The provider had upgraded and improved the physical condition of consultation and treatment rooms within the practice. New flooring had been fitted, walls had been repainted, and new lighting, wall mounted water heaters and ventilation had been installed or otherwise improved.
- The provider had completed immunity status checks for clinical and non-clinical staff.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
- The provider had improved performance in relation to child immunisations since the last inspection in 2019. Two of the five child immunisation measures still remained below the minimum target of 90% but the practice had taken action to encourage uptake.
- The provider had ensured that a previous small backlog of correspondence had been dealt with. At the time of this inspection there was no backlog of correspondence.
- Performance in relation to cancer reviews undertaken had improved since the last inspection. For example, the percentage of patients with cancer, diagnosed within the preceding 15 months, who have had a patient review recorded as occurring within six months of the date of diagnosis had risen from 60% in 2017/18 to 100% in 2019/20.
Whilst we found no breaches of regulations, the provider should:
- Continue to work to improve child immunisation rates.
- Complete a high level clean of the roof light area in Room 11.
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