The Care Quality Commission
  • Doctor
  • GP practice

Shaftesbury Medical Centre Also known as Dr Darbyshire and partners

Overall: Good read more about inspection ratings

78 Osmondthorpe Lane, Leeds, West Yorkshire, LS9 9EF (0113) 240 9500

Provided and run by:
Shaftesbury Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Shaftesbury Medical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Shaftesbury Medical Centre, you can give feedback on this service.

28 April 2021

During an inspection looking at part of the service

We carried out an announced focused inspection at Shaftesbury Medical Centre on 28 April 2021.

We focused our inspection on the key question of:

  • Are services safe.

The practice remains rated as good overall and now good for providing safe services.

Following our previous inspection on 7 November 2019, the practice was rated as good overall and for the key questions of effective, caring, responsive and well-led. The practice was rated as requires improvement for providing safe service, with a breach of Regulation 12 of the Health and Safety Care Act 2008 (Regulated Activities) Regulations 2014 safe care and treatment.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Shaftesbury Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

In November 2020 we had undertaken a monitoring call with the provider, where we were informed that they had completed all the actions relating to the breach of Regulation 12.

This was a focused inspection to check those actions had been completed and were embedded throughout the practice.

At the last inspection we found:

  • Storage of vaccines in the refrigerators was not in line with best practice and that some vaccines had expired.
  • Sharps waste was not managed in line with best practice.
  • Some expired medicines and other products, including vaccines, swabs, sterile bags and oxygen masks.
  • Arrangements to respond to emergencies were not well embedded within the practice. At the branch location, some emergency medicines were stored in separate areas, which could have delayed the administration of those medicines in an emergency.

How we carried out the inspection

Throughout the pandemic the Care Quality Commission (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:

  • A site visit to both locations.
  • A review of documents specific to the issues identified at the previous inspection.

Our findings

We found that the practice had made the necessary improvements:

  • Vaccines were stored in line with best practice. We observed that vaccines were in date and there was a clear process regarding stock control and the checking of expiry dates. Expired vaccines were disposed of in line with relevant guidance.
  • Sharps waste was managed in line with best practice. There was a clear process for the management and storing of sharps waste. All sharps waste bins were labelled and stored securely.
  • There was a clear process for the management of medicines and products, such as swabs and oxygen masks, to ensure they were all in date.
  • Emergency medicines and equipment were stored together in a secure room. Staff knew how to access them should they be needed in an emergency.
  • All improvements had been implemented across both of the practice locations.
  • Staff were aware of the improvements, which had been embedded within the practice.

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

During an inspection looking at part of the service

We carried out an announced focused inspection at Shaftesbury Medical Centre on 7 November 2019 as part of our inspection programme. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions:

  • Are services safe?
  • Are services responsive?
  • Are services effective?
  • Are services well-led?

As a result of concerns identified during our inspection, we expanded the scope to also inspect the key question of safe.

Because of the assurance received from our review of information we carried forward the ratings for the following key questions:

  • Are services caring?

We based our judgement of the quality of care at this service is based on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services
  • information from the provider, patients, the public and other organisations.

We have rated this practice as good overall but requires improvement for providing safe services.

We concluded that:

  • The practice undertook some quality improvement activity in order to monitor and improve outcomes for patients.
  • Staff made use of a number of care planning templates providing holistic assessment and delivery of care for patients.
  • Oversight of practice performance was maintained in relation to quality and outcomes framework (QOF) achievements and patient feedback.
  • A suite of regularly updated practice policies and protocols supported governance systems.
  • Staff told us they felt supported by the GPs and management team at the practice.
  • Some of the medicines we checked were not in date. At the branch location some emergency drugs were stored in separate areas which could delay the administration of these medicines in an emergency.

The provider must :

  • Ensure care and treatment is provided in a safe way to patients.

The provider should :

  • Improve the uptake of childhood immunisations at the practice and ensure that the World Health Organisation minimum target of 90% is met for all indicators.
  • Improve the uptake of cancer screening at the practice including cervical screening.
  • Take action to reduce QOF exception reporting for diabetes and long-term conditions.

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

4 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Shaftesbury Medical Centre on 4 May 2016. Overall the practice is rated as good for providing safe, effective, caring, responsive and well-led care for all of the population groups it serves.

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

  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Risks to patients were assessed and well managed. There were good governance arrangements and appropriate policies in place.
  • Information regarding the services provided by the practice was available for patients.
  • The practice had good facilities and was well equipped to treat and meet the needs of patients.
  • Patients said they were treated with compassion, dignity and respect and were involved in care and decisions about their treatment.
  • The majority of patients were positive about access to the service. They said they generally found it easy to make an appointment, there was continuity of care and urgent appointments were available on the same day as requested.
  • The practice sought patient views how improvements could be made to the service, through the use of patient surveys, the NHS Friends and Family Test and the patient participation group.
  • There was a complaints policy and clear information available for patients who wished to make a complaint.
  • The practice was aware of and complied with the requirements of the duty of candour. (The duty of candour is a set of specific legal requirements that providers of services must follow when things go wrong with care and treatment.)
  • The partners promoted a culture of openness and honesty and there was a comprehensive ‘being open’ policy in place, which was reflected in their approach to safety. All staff were encouraged and supported to record any incidents using the electronic reporting system. There was evidence of good investigation, learning and sharing mechanisms in place.
  • There was a clear leadership structure and a stable workforce in place; the majority of staff had worked there for over 10 years. Staff were aware of their roles and responsibilities and told us the GPs and manager were accessible and supportive.
  • The practice had high praise for their staff and clearly appreciated and valued their input.

However, there was an area where the provider should make an improvement:

  • The practice should take steps to reduce the probability of accidental interruption of the electrical supply to vaccine fridges.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

9 December 2013

During a routine inspection

We spoke with four patients about the service and eight staff at Shaftesbury Medical Centre. Patients told us they felt their health needs had been met by a very welcoming and friendly team who were competent to do their jobs.

Patient's needs were assessed and care and treatment was planned and delivered in line with their individual wishes. One person told, 'It's usually easy getting an appointment, but it depends when you ring, I don't think I've been kept waiting at all.'

Another person told us, 'I can usually see the doctor I want' and 'I was given some information on diet and I've seen the website and the practice leaflet. The building is nice, clean and comfortable. So much better than the old place.'

The training records we viewed confirmed all staff had received training in protection of vulnerable adults and children. All of the staff we spoke with reported good access to training opportunities, for example one person has done a phlebotomy course.

The provider had carried out monitoring of chronic conditions, how the practice was organised, patient views and extra services provided.

This monitoring was required as part of Quality Outcomes Framework (QOF). The provider told us they were meeting most of the targets and we saw evidence of this.