• Doctor
  • GP practice

Undercliffe Surgery

Overall: Good read more about inspection ratings

16 Union Street, Heckmondwike, West Yorkshire, WF16 0HH (01924) 403406

Provided and run by:
Undercliffe Surgery

Latest inspection summary

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Background to this inspection

Updated 5 November 2018

Undercliffe Surgery is situated at 16 Union Street, Heckmondwike WF16 0HH. The website for the practice is www/undercliffe.gpsurgery.net/ . The practice is registered with the Care Quality Commission to carry out the following regulated activities:

  • Maternity and midwifery services
  • Surgical procedures
  • Treatment of disease, disorder or injury
  • Diagnostic and screening procedures
  • Family planning

There are currently 10,994 patients registered on the practice list. The practice provides General Medical Services (GMS) under a locally agreed contract with NHS England.

The Public Health National General Practice Profile shows that around 23% of the practice population are of black or other mixed ethnicity, with around 77% of white origin. The level of deprivation within the practice population group is rated as four, on a scale of one to ten. Level one represents the highest level of deprivation, and level ten the lowest.

The age/sex distribution profile of the practice is in line with local and national averages. The average life expectancy for patients at the practice is 79 years for men and 81 years for women, which is in line with the national average of 79 years and 83 years respectively.

The practice offers a range of enhanced services which include childhood vaccinations and immunisations, and minor surgery.

The clinical team comprises three GP partners, two male and one female, and two salaried GPs, one male and one female. In addition, a regular male locum GP is employed by the practice. There are two practice nurses, one nurse practitioner, one advanced care practitioner and two health care assistants, all of whom are female.

Supporting the clinical team is a practice manager, reception manager and a range of reception, secretarial and administrative staff. The practice manager is a member of the local practice manager forum and sits on the federation board. The reception manager is a member of the local practice manager strategy group.

The practice is a training practice, which means it supports fully qualified doctors wishing to specialise in general practice. In addition, a range of other staff are supported to gain additional qualifications, such as support to achieve nurse practitioner or clinical practitioner status. The practice is part of the local federation, and one of the GP partners is a founding member of the federation.

The practice is open between 8am and 6.30pm Monday to Friday, with one late opening until 8pm per week which varies between Tuesday and Thursday evening. The practice participates in the extended access scheme, delivered through the local federation. This means that patients are able to access pre-booked appointments at another site between 6.30pm and 9.15pm Monday to Friday, Saturday from 9am to 3.45pm and Sunday from 9am to 12.45pm.

The practice is housed in purpose built premises which is shared with another practice. All patient consulting rooms are located on the ground floor. The building is accessible to patients with mobility problems, or those who use a wheelchair. The site provides adequate parking spaces with dedicated disabled parking spaces, and the practice is accessible by public transport.

Out of hours care is provided by Local Care Direct which is accessed by calling the surgery telephone number, or by calling the NHS 111 service.

When we returned to the practice; we checked, and saw that the ratings from the previous inspection were displayed, as required, on the practice premises and on their website.

Overall inspection

Good

Updated 5 November 2018

This practice is rated as Good overall. The practice was previously inspected on 28 September 2016 when it received a rating of good overall, but requires improvement for providing safe services. A focused follow up inspection was carried out on 24 May 2017, when the identified issues had been resolved, and the practice received a rating of good for providing safe services.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Undercliffe Surgery on 10 October 2018, as part of our inspection programme.

At this inspection we found:

  • The practice significant incident reporting system was embedded throughout the practice. We saw that staff felt supported to report incidents; and that learning and improvements following incidents were disseminated to all staff.
  • There were a number of practice specific policies and protocols which were regularly reviewed, and were accessible to all staff on the practice computer system.
  • The practice carried out quality improvement activities which demonstrated improved patient outcomes. Care and treatment was delivered in line with current, evidence based guidance.
  • We observed staff dealing with patients in a respectful and considerate manner. Feedback we received from patients confirmed this.
  • National GP patient survey results, published in August 2018 showed a high level of patient satisfaction in relation to accessing the service, and in relation to the care and treatment they received.
  • The practice had a strong focus on learning and development. Staff were supported to develop in key roles which supported new models of care delivery.

The areas where the provider should make improvements are:

  • Maintain safe processes in relation to Disclosure and Barring Service (DBS) checks for new recruits, and for non-clinical staff undertaking chaperone duties.
  • Continue to ensure that all staff receive safeguarding training and updates at the level appropriate to their role.
  • Review staff immunisation status in line with Public Health England guidelines.

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