Beeston Village Surgery

Updated 8 August 2022

Beeston Village Surgery is located at James Reed House, Town Street, Beeston, Leeds LS11 8PN. The premises are leased by the practice from NHS property services and consists of a modern, purpose-built health centre, which also houses a community renal dialysis satellite service. All patient access areas, such as reception and consulting rooms, are all located on the ground floor. There is disabled access to the premises. Onsite parking also has disabled parking spaces. There are good transport links and community facilities, including a pharmacy, in the surrounding area.

The provider of Beeston Village Surgery is registered with the Care Quality Commission (CQC) to deliver the Regulated Activities of diagnostic and screening procedures, treatment of disease, disorder or injury, maternity and midwifery services, family planning and surgical procedures.

The practice is situated within NHS Leeds Clinical Commissioning Group (CCG) who, from 1 July 2022, are now known as the NHS West Yorkshire Integrated Care Board (ICB). The practice is part of a wider network of GP practices, known as a Primary Care Network (PCN).

Information published by Public Health England rates the level of deprivation within the practice population group as being decile one. (On a scale of one to ten, decile one represents the highest levels of deprivation and decile ten the lowest.)

The provider holds a Primary Medical Services (PMS) contract to deliver services to 7,427 patients. According to the latest available data, the ethnic make-up of the practice is 82% White, 10% Asian, 4% Black with the remaining of mixed and other. The gender distribution of the patient population shows there are similar numbers of male and female. In comparison with England averages, there are higher numbers of young people (26% compared to 20%) and lower numbers of older people (9% compared to 18%).

The clinical team consists of a male lead GP (provider), three salaried GPs (1 female, 2 male) one advanced clinical practitioner, three practice nurses and two healthcare assistants (all female). The non-clinical staff consists of a practice manager, a practice secretary and a team of patient care advisors with a team leader.

The practice opening hours are as follows:

Monday 7am to 6pm

Tuesday 7.30am to 6pm

Wednesday 7am to 6pm

Thursday 7.30am to 6pm

Friday 8am to 6pm

Appointments, which include face to face and telephone, are available for patients during these times. Requests for home visits can be made to the practice, which will be discussed with the duty doctor. Patients also have access to online requests via the practice website.

Out of hours cover is provided by Local Care Direct. Patients are directed to contact NHS 111 when the practice is closed; should the need arise.

Weekend extended access, between 9am and 3pm on Saturday and Sunday, is provided locally by Leeds GP Confederation.

The practice has recently achieved training status and will be supporting GP registrars from August 2022. They also provide support for year three undergraduate medical students on an annual basis.

Updated 8 August 2022

We carried out an announced comprehensive inspection at Beeston Village Surgery on 12 and 14 July 2022.

Following this inspection, we rated the location as good overall and the following for each key question:

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led – Good

Why we carried out this inspection

This announced comprehensive inspection was carried out following changes to the provider registration and legal entity of the practice. This was the first inspection since this change.

Under their previous registration, the practice was inspected on 17 April 2018. At that inspection, the practice was rated good overall and for all key questions of safe, effective, caring, responsive and well-led. The full report for that inspection can be found by selecting the ‘all reports’ link for Beeston Village Surgery 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:

• Requesting evidence from the provider.
• Conducting some staff interviews via telephone.
• Practice staff completing questionnaires.
• 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
• 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, patients, the public and other organisations.

We have rated this practice as Good overall.

We found that:

• There were systems in place to safeguard children and vulnerable adults from abuse and staff knew how to identify and report safeguarding concerns.
• Leaders reviewed the effectiveness and appropriateness of the care the service provided. They ensured that care and treatment was delivered according to evidence-based guidelines.
• The practice had adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• Staff had the skills, knowledge and experience to deliver effective care.
• The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Leaders demonstrated they had the capacity and skills to deliver high-quality, sustainable care.

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

• Embed and monitor the revised process for the management of patient safety alerts.
• Improve the recall and follow-up processes for the monitoring of patients who are prescribed high-risk medicines.
• Improve the recall and follow-up processes for the monitoring and coding of patients who may be identified as pre-diabetic.

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