The Care Quality Commission
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Archived: Bramley Village Health and Wellbeing Centre

Overall: Good read more about inspection ratings

Highfield Road, Bramley, Leeds, West Yorkshire, LS13 2BL (0113) 256 3250

Provided and run by:
Bramley Village Health and Wellbeing Centre

Important: The provider of this service changed. See new profile

All Inspections

13 June to 13 June

During a routine inspection

We carried out an announced comprehensive inspection at Bramley Village Health and Wellbeing Centre on 13 June 2019 as part of our inspection programme.

At the last inspection in May 2018 we rated the practice as requires improvement for providing safe services because:

  • There had been no fire drills carried out by the provider to ensure all staff were aware of evacuation routes.
  • The provider had not offered staff vaccinations and immunisations in line with Department of Health Guidelines.

At this inspection, we found that the provider had taken steps to address these areas.

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 good for all population groups.

We found that:

  • The practice could demonstrate significant improvement against the Quality and Outcomes Framework.
  • The practice had improved identification and management of people with a long-term condition.
  • Patients received effective care and treatment that met their needs.
  • The practice responded to feedback from patients regarding the services they delivered.
  • The provider was aware of the challenges facing the practice and had taken steps to address these.

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

  • Review and improve staffing levels and contingency planning to promote accessible services across all three sites.
  • Continue to support reception and administrative staff with appropriate care navigation training.
  • Review and improve communication systems in place across all three sites.
  • Review and where necessary, update safeguarding training for nursing and administrative staff in line with new intercollegiate guidance issued by the Royal College of Nursing.

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

3 May 2018

During a routine inspection

This practice is rated as Good overall, but requires improvement for providing safe services. (The previous comprehensive inspection was carried out on 31 August 2017 when the practice was rated inadequate overall)

The key questions are rated as:

Are services safe? – Requires Improvement

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 The Highfield Medical Centre on 31 August 2017. The overall rating for the practice was inadequate. The full comprehensive report on the August 2017 inspection can be found by selecting the ‘all reports’ link for The Highfield Medical Centre on our website at .

This inspection was an announced comprehensive inspection carried out on 3 May 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on31 August 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At this inspection we found:

  • The practice had 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 arrangements to ensure that the premises, facilities and equipment were safe and in good working order. However; at the time of inspection we were unable to see evidence that the provider was carrying out annual fire drills in line with HM Government Fire Safety Risk Assessment for healthcare premises guidance.
  • The practice had a system for reviewing and discussing Medicines Health Regulatory Authority (MHRA) alerts, patient safety alerts and NICE guidance.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • We saw evidence of improved governance systems including the implementation of clinical templates to ensure standardised care in line with current evidence based guidelines.
  • There was a focus on continuous learning and improvement at all levels of the organisation.
  • The practice had a business vision and strategy to promote healthy outcomes for patients and all of the staff we spoke with felt supported by management.

The areas where the provider should make improvements are:

  • Review and improve the systems in place to ensure staff and patients are protected from the risk of fire at the premises by introducing a schedule of fire drills (this is particularly important when the refurbishment works are completed to ensure all staff are aware of evacuation routes).
  • Continue to review and improve quality and outcomes framework performance and exception reporting, particularly around the care and treatment provided to patients with mental health conditions.
  • Review and improve the range of vaccinations and immunisations offered to staff in line with Department of Health Guidelines.

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

18 December 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection of The Highfield Medical Centre on 31 August 2017. We identified three breaches of regulations and issued warning notices at provider and registered manager level on all three regulatory breaches. This resulted in six warning notices being issued as a result of the inspection against the following regulations:

  • Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Safe care and treatment.
  • Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Good Governance.
  • Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Staffing.

We told the provider they must be compliant with Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 by 30 November 2017. We carried out this focused follow-up inspection on 18 December 2017. This report covers our findings in relation to this requirement only. The dates by which the provider has to comply with legal requirements for the other warning notices had not been reached at the time of this inspection. You can read the report from the last inspection carried out on 31 August 2017 by selecting the reports link for The Highfield Medical Centre on our website at www.cqc.org.uk.

Our key findings were as follows:

Improvements had been made with respect to patient safety following our last inspection on 31 August 2017. For example:

  • The practice had implemented a new process for receiving, reviewing and actioning Medicines and Health Regulatory Alerts (MHRA) and other patient safety alerts. There was a dedicated lead to review all alerts and any requiring action were reviewed at joint practice and clinical meeting held every two weeks.
  • The practice had introduced a new system to report incidents and near misses. All staff were aware of the system, and incidents and near misses were discussed at joint clinical and practice meetings held every two weeks.
  • We saw that steps had been taken to improve infection prevention and control procedures within the practice.

However, there was one area of practice where the provider should make and maintain improvements:

  • The practice should continue to focus on improving the timeliness of patient referrals in order to meet their own 48 hour processing target.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

31 August 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We undertook a comprehensive inspection of The Highfield Medical Centre on 1 December 2016. The practice was rated as requires improvement overall, as they were not providing safe and well-led care. We asked them to submit an action plan setting out how they would improve systems and processes within the practice and the date by which these improvements would be implemented. The full comprehensive report on the December 2016 inspection can be found by selecting the ‘all reports’ link for The Highfield Medical Centre on our website at www.cqc.org.uk.

We undertook a further announced comprehensive inspection of The Highfield Medical Centre on 31 August 2017. This inspection was carried out following confirmation from the practice that all actions had been carried out and improvements had been made following our December 2016 inspection. At this inspection we found that some areas from the last inspection had not been addressed. For example; we found there were still issues with infection prevention and control and significant event recording. We also identified further areas of concern and the practice is now rated as inadequate overall.

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

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example; we saw no evidence that Medicines and Health Regulatory (MHRA), or other patient safety alerts were discussed by the clinical team. An annual Infection Prevention and Control audit had taken place in October 2016; however the provider had not taken steps to ensure that all actions had been addressed. We also found that patient referrals to other services were not always being carried out in a timely way.
  • The reporting and actioning of significant events was inconsistent and lessons learned were not always clear or documented.
  • Some of the staff we spoke with told us there was a shortage of staff or that the workload was too high in order to carry out their role safely.
  • There was little or no evidence of audits or quality improvement activity within the practice.
  • There was limited evidence of governance oversight or a clear lead for governance areas. Some of the staff we spoke with were aware of the whistleblowing policy but were reluctant to invoke it due to the dynamics within the leadership team.
  • We saw no evidence of partners within the practice working together to improve the service provided.
  • We were not assured that appropriate recruitment processes were followed in all cases.
  • There had only been limited progress made with regard to the areas identified as requiring improvement during the inspection carried out in December 2016.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The areas where the provider should make improvement are:

  • The provider should review their agenda structure for the meetings which are currently taking place to encourage full staff participation and act as a prompt to cover relevant topics (such as complaints) on a regular basis.
  • The practice should establish a clear lead for reviewing and updating practice policies.
  • The provider should look at ways to increase uptake of breast and bowel screening within the practice.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

1 December 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Highfield Medical Centre on 1 December 2016. Overall the practice is rated as requires improvement.

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

  • The practice was involved in the Leeds West Chronic Obstructive Pulmonary Disease Scheme (COPD) to increase early detection of COPD and reduce hospital admission where possible. As a result of undertaking this work, the practice prevalence for COPD had increased to meet the national prevalence and the practice saw a reduction in A&E attendance.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were not thorough enough. Patients did not always receive an apology.
  • Most risks to patients were assessed and well managed. We saw that a legionella risk assessment had been carried out and an action plan created as a result of this. However; at the time we saw no evidence of the actions having been carried out. Some recruitment processes had not been thorough; we saw that one member of staff had been recruited without references having been received.
  • We saw that not all patient clinical records contained evidence of assessment of patient need, and details of planned treatment and care of patients.
  • Although some audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes.
  • The majority of patients said they were treated with compassion, dignity and respect. However; we received feedback via CQC comment cards and through information of concerns submitted to CQC prior to the inspection regarding the manner of some clinical staff.

The areas where the provider must make improvements are:

  • The provider was not doing all that was reasonably practicable to mitigate the risks of service users receiving care and treatment. Specifically, there was no evidence of lessons learned from significant events and incidents and no evidence of any learning from these being shared with relevant practice staff.
  • Ensure that accurate, complete and contemporaneous records are kept for patients; which include a record of care and treatment provided and decisions taken in relation to this. In addition, records were not mainitained to support the investigations and findings resulting from complaints the practice had received in all cases.

In addition the provider should:

  • Follow their recruitment policy in full at all times when recruiting staff.
  • Continue to maintain a process for logging and checking of all prescriptions used in the practice.
  • Review and complete actions identified on infection control and legionella action plans.
  • Develop consistent processes for the appropriate recall and treatment of patients with long term or enduring physical or mental health problems.
  • Establish a system of regular clinical audit within the practice to demonstrate improved outcomes for patients.
  • Take steps to assure themselves that patients are being treated with dignity and respect at all times.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice