The Care Quality Commission
  • Doctor
  • GP practice

Burley Park Medical Centre

Overall: Good read more about inspection ratings

273 Burley Road, Leeds, West Yorkshire, LS4 2EL (0113) 295 3850

Provided and run by:
Burley Park 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 Burley Park 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 Burley Park Medical Centre, you can give feedback on this service.

17 November 2021

During a routine inspection

We carried out an announced inspection at Burley Park Medical Centre on 16 and 17 November 2021. Overall, the practice is rated as Good.

The ratings for each key question are:

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

Following our previous inspection on 10 December 2015, the practice was rated good overall and for all key questions, except for providing responsive care which was rated as outstanding. At this inspection we rated the practice as good for providing responsive services. We did not see a deterioration in standards at this inspection, but many of the initiatives which the practice undertook in December 2015 are now widely recognised as good practice and in place across the clinical commissioning group and nationally.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Burley Park Medical Centre 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:

  • Conducting staff interviews using telephone and 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 site visit which included face to face interviews with 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 practice as Good overall and for all key questions.

We found that:

  • The support offered by the team to two local care homes was described by the home managers as exceptionally positive. Weekly reviews of the residents’ needs were carried out and visits made on request throughout the COVID-19 pandemic. The team was described as offering respectful, kind and safe care.
  • The practice was experienced in offering Gender Dysphoria services to patients. Regular searches were run to identify patients who may be in need of support. When gender specific cancer screening services were indicated, each patient was individually contacted by an experienced clinician to offer guidance and support.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. The team reviewed their appointment system in April 2021 and when an appointment was needed, patients were given the choice of a telephone or face to face appointment at each contact. Face to face consultations were conducted when this was clinically necessary.
  • Patients could book these appointments on the day or in advance. Urgent appointments were available every day for those with enhanced needs and complex medical issues. At the time of our inspection between 60 to 70% of the appointments offered at the practice were face to face.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • Staff told us that leaders were consistently supportive, helpful, knowledgeable and approachable at all times. Leaders at the practice told us this support was mutual.

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

  • Continue with newly implemented plans to review and retain overall responsibility for individual independent non-medical prescribers to ensure that they have the necessary skills and knowledge to carry out the role.
  • Continue with agreed plans to review historical safety alerts, to reduce the potential for error with patients who take a combination of medicines which may interact with each other.
  • Review the management of complaints and significant events to ensure that outcomes, learning and changes made following the recording of these issues are documented and shared with the staff team.
  • Continue to review and embed changes made to the use of the clinical records system, to ensure that patients’ recalls and additional interventions, such as the need to undertake reviews and monitoring, are responded to in a timely manner.
  • Take action to ensure evidence of Disclosure and Barring Service (DBS) checks for all members of the team is documented.
  • Continue to update the level of safeguarding training undertaken by non-clinical staff.

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

10/12/2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Burley Park Medical Centre on Thursday 10th December 2015. Overall the practice is rated as good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example the Quality Improvement Scheme for cervical cytology, working with five other practices.
  • Feedback from patients about their care was positive.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet people’s needs. For example the service on weekends and bank holidays.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group (PPG). For example changing the times of the Paediatric asthma clinic and extended opening hours.
  • The practice had good, well maintained facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand
  • The practice had a clear vision which had quality and safety as a priority. The strategy to deliver this vision was regularly reviewed and discussed with staff.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.
  • We saw several areas of outstanding practice including:
  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet people’s needs. For example, the practice worked with the CCG and another practice to provide a service on Saturdays, Sundays and bank holidays. This a CCG hub initiative with the Practice being a keen early adopter and which has provided noticeable reductions in accident and emergency (A & E) and demands on the practice at peak times such as Monday mornings.
  • The practice provided a GP service to two local care/nursing homes in the area. This included planned weekly visits by a named GP. This service had been running for over 20 years and we were told that there is anecdotal evidence that these homes have the lowest admission rate in the Leeds area. The practice was highly commended by the CCG on the quality of their application for the care home local enhanced service (LES) and was described as a ‘Gold standard for providing this level of care' by the clinical lead for long term conditions.  
  • Burley 2000 lunch club was set up by the practice, in collaboration with the local church, to help to reduce the feelings of loneliness and isolation of older people.
  • The needs of vulnerable people such as the homeless or substance mis-users were discussed in clinical meetings. The practice had established links with a local bail hostel to support the development of a service for the residents.

However there were areas of practice where the provider should make improvements:

  • Ensure all staff, have annual appraisals.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice