The Care Quality Commission
  • Doctor
  • GP practice

The Practice Lincoln Green

Overall: Good read more about inspection ratings

Burmantofts Health Centre, Cromwell Mount, Leeds, West Yorkshire, LS9 7TA (0113) 221 1900

Provided and run by:
Chilvers & McCrea Limited

All Inspections

During an assessment under our new approach

The Practice Lincoln Green is an NHS GP practice which provides primary care services to patients in an area of Leeds, West Yorkshire. We carried out an announced assessment of one quality statement, equity of access, under the key question Responsive at The Practice Lincoln Green on the 4 March 2024. We carried out the assessment as part of our work to understand how practices are working to try to meet peoples demands for access and to better understand the experiences of people who use services and providers. We recognise the work that GP practices have been engaged in to continue to provide safe, quality care to the people they serve. We know staff are carrying this out whilst the demand for general practice remains exceptionally high, with more appointments being provided than ever. However, in this challenging context, access to general practice remains a concern for people. Our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. The assessment of the quality statement equity of access includes looking at what practices are doing innovatively to improve patient access to primary care and sharing this information to drive improvement. Overall, the practice is rated as good and the key question responsive continues to be rated as providing a good service. We found that the practice had organised services to meet patients’ needs, particularly those who were most likely to have difficulty accessing care, so that people can access care, treatment and support when they need it and in a way that works for them. The practice gathered, analysed and used feedback and other data/information to monitor and improve access.

25 August 2022

During a routine inspection

We carried out an announced comprehensive inspection at The Practice Lincoln Green on 25 August 2022. Following this inspection, we rated the location as Good and for each key question:

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 19 November 2015, the practice was rated Good overall and for the key questions of safe, effective, caring and well-led. At the last inspection we rated the practice as outstanding for providing responsive services because:

  • Educational workshops were provided for patients who had a diagnosis of diabetes to improve their understanding and self-management. The practice also delivered educational sessions in a local primary school and supermarket.
  • One of the practice nurses had co-founded the Leeds Respiratory Network Group.
  • Mindfulness and guided meditation sessions were provided for patients.
  • There was a proactive approach to the education of patients and they could evidence a reduction in accident and emergency attendances as a result.

At this inspection, we found that some of those areas previously regarded as outstanding practice were no longer in operation, as a result of staff leaving the practice and shortfalls in staffing overall. At this inspection, the threshold for achieving an outstanding rating had not been reached. The practice is therefore now rated good for providing responsive services.

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

Why we carried out this inspection

This comprehensive inspection was undertaken in line with our inspection priorities.

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 as possible. 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 and teleconferencing.
  • 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 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 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.

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

  • Continue to undertake recruitment processes, and/or review staffing structures, to ensure there are enough clinical staff to deliver services.
  • Summarise any outstanding patient records to ensure that all information is available for the delivery of safe patient care and treatment.
  • Continue to look at ways of improving uptake rates for childhood immunisations and cancer screening of breast, bowel and cervical.
  • Continue to have regular, minuted meetings, such as clinical, safeguarding and palliative care, to support the delivery of patient care and treatment.
  • Improve the identification of carers.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

19 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Practice Lincoln Green on 19 November 2015. Overall the practice is rated as good for providing safe, effective, caring and well-led care for the population groups it serves. However, we found the practice rated as outstanding for the responsive care of people with long term conditions and those experiencing poor mental health (including dementia).

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

  • Patients’ needs were assessed and staff had the skills, knowledge and experience to deliver effective care and treatment in line with current evidence based guidance
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • Information about services and how to complain was available and easy to understand.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • National survey patient responses said they sometimes found it difficult to make an appointment. However, a practice based survey showed more positive results. Urgent appointments were available for the same day as requested.
  • Risks to patients’ health and safety were assessed and well managed. There were effective safeguarding processes in place.
  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • There was a clear leadership structure and staff felt supported by management.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

We saw several areas of outstanding practice:

  • Members of the nursing team provided mindfulness and guided meditation sessions for patients; particularly those who had a mental health related issue or multiple long term conditions.
  • 100% of patients with dementia and 98% of patients with poor mental health had received a comprehensive review and documented care plan in the last twelve months. These were higher than the CCG averages of 88% for both.
  • There was a proactive approach to the education of patients, especially those who attended accident and emergency (A&E) inappropriately. The practice could evidence a reduction in A&E attendances over the past 12 months.
  • Educational workshops were provided for patients who had a diagnosis of diabetes to improve their understanding and self-management. The practice also delivered educational sessions in a local primary school and supermarket.
  • One of the practice nurses had co-founded the Leeds Respiratory Network Group. The network provided education, support, forum, website and blog for a range of health professionals.

However, there was an area where the practice should improve:

  • To maintain an accurate record of what medicines are stored in the GPs’ bags.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice