Archived: Mowbray Square

We carried out an announced comprehensive inspection of the extended access service run by Yorkshire Health Network on 16 May 2022. Overall, the provider is rated as good.

The key questions are rated as:

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led – Good

Why we carried out this inspection

This announced comprehensive inspection was the provider’s first inspection. We looked at the key questions safe, effective, caring, responsive and well-led.

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 face to face and video conferencing;
• requesting feedback from staff electronically;
• requesting evidence from the provider;
• reviewing patient records to identify issues and clarify actions taken by the provider; and
• a site visit to the head office and one site where the service is delivered from

As part of this inspection we received feedback via face to face interview, video conference interview, discussions with staff working on-site and an electronic questionnaire. This feedback came from members of the management team, clinical and non-clinical 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 provider as good overall.

We found that:

• The provider continued to contribute to the local health agenda and work in partnership with stakeholders to deliver patient care during the challenges of the past year with the COVID-19 pandemic.
• The service had systems in place to keep people safe and safeguarded from abuse. Staff we spoke with knew how to identify and report safeguarding concerns.
• The provider regularly carried out quality improvement activity, including clinical audit, and routinely reviewed the effectiveness and appropriateness of the care provided.
• Staff had the skills, knowledge and experience to deliver effective care.
• Staff involved and treated people with compassion, kindness, dignity and respect.
• Leaders demonstrated they had the capacity and skills to deliver high-quality, sustainable care.
• Patient feedback about the service had been positive.

The areas where the provider should make improvements are:

The provider should continue to develop governance and quality assurance processes in respect of the below:

• Review and improve systems for recording the immunisation status of staff.
• Review and improve the arrangements in place for staff in respect of fire evacuation when an on-site service is in operation.
• Improve governance and oversight processes so that all staff complete required training in a timely way.
• Develop staff awareness of the Freedom to Speak Up Guardian
• Review and improve the arrangements in place to monitor that the provider’s policy is being followed in respect of vulnerable patients/children that Do not Attend (DNA) appointments.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care