Kirkstall Lane Medical Centre

Updated 15 July 2022

Kirkstall Lane Medical Centre operates from purpose-built premises located at 216 Kirkstall Lane, Headingley, Leeds, LS6 3DS.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services, treatment of disease, disorder or injury and surgical procedures.

Kirkstall Lane Medical Centre is situated within the NHS Leeds Clinical Commissioning Group (CCG) and provides services to 7,140 patients under the terms of a general medical services (GMS) contract. This is a contract between general practices and NHS England for delivering services to the local community.

The service is provided by a partnership consisting of three GP partners (one female and two male), an advanced nurse practitioner (female), two practice nurses (female), a health care assistant and a care coordinator (both female). The clinical staff are supported by an experienced practice manager and a team of secretarial and reception staff.

The practice is part of the Woodsley Primary Care Network (PCN). PCNs are a group of practices working together to focus care on the needs of the local population.

The National General Practice Profile states that the practice population is predominantly white, making up 84% of the registered patient list size; 8% are from an Asian background with a further 8% orginating from black, mixed or other non-white ethnic groups.

Information published by Public Health England, rates the level of deprivation within the practice population group as five, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.

The practice has a higher than CCG and national average number of patients between the ages of 20 and 44 years. However distribution of the practice population closely mirrors the local and national averages.

The practice is open between 8.00am to 6.30pm Monday to Friday. In addition in-house extended hours are available from 7.00am until 8.00am on Thursday mornings. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally, where late evening and weekend appointments are available. Out of hours services are provided by NHS 111.

Updated 15 July 2022

We carried out an announced comprehensive inspection at Kirkstall Lane Medical Centre on 15 and 16 June 2022. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive – Good

Well-led - Good

The practice was previously inspected on 10 March 2016 and was rated outstanding overall and for providing responsive and well-led services.

At this inspection we noted that areas previously regarding as outstanding practice were now embedded within other GP practices. While the provider maintained many of these good practices, the threshold to achieve an outstanding rating had not been reached. The practice is therefore now rated good for providing responsive and well-led services.

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

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.

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 video conferencing
• 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
• Requesting evidence from the provider
• A short site visit
• Staff questionnaires sent to staff ahead of the inspection

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

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• The practice had good systems in place to identify and support patients at risk of or suffering from abuse. Staff worked regularly with other stakeholders such as health visitors and palliative care nurses to support those patients.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• The practice responded to feedback from patients and staff regarding access to services and tailored the appointment system to best meet the needs of the patient population.
• All staff felt supported by the manager and GP partners. They reported Kirkstall Lane Medical Centre to be a good place to work.

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

• Maintain a record of safety alerts relevant to the practice and action taken as a result of these.
• Improve systems for sharing learning from significant events to ensure all staff are included in this process.
• Implement processes for checking registration with professional bodies such as Nursing and Midwifery Council to ensure all staff have renewed registration.
• Continue to take steps to identify registered patients who are also carrying out the role of a carer.
• Improve uptake of cervical screening.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.