Windsor House Group Practice

Updated 5 December 2016

Windsor House Group Practice operates from the following three sites:

Windsor House Surgery which is located at 2 Corporation Street, Morley, Leeds, LS27 9NB. Shenstone House Surgery which is located on Elland Road, Churwell, Morley, Leeds, LS27 7PX, and Adwalton House Surgery, 1 – 3 Wakefield Road, Drighlington, Bradford, BD11 1DH. The practice serves a population of approximately 15,823 patients and services can be accessed across all site. We based the main inspection at Adwalton House Surgery; however we visited all three sites as part of our inspection.

The practice is situation within the Leeds West Clinical Commissioning Group (CCG) and is registered with the Care Quality Commission (CQC) to provide primary medical services under the terms of a personal medical services (PMS) contract. This is a contract between general practices and NHS England for delivering services to the local community.

Windsor House Surgery is open as follows:

Monday, Wednesday and Thursday from 8am until 8pm

Tuesday from 8am until 6pm

Friday from 7am until 7pm

Shenstone House is open as follows:

Monday to Thursday from 8am until 6pm

Friday from 7am until 6pm

Adwalton House is open as follows:

Monday, Wednesday and Thursday from 8am until 6pm

Tuesday from 8am until 8pm

Friday from 7am until 6pm

The service is provided by five GP partners (four male and one female) and two female salaried GPs. The practice also has an advanced nurse practitioner (female), three practice nurses and a health care assistant. The clinical staff are supported by a practice manager and an experienced team of administrative and reception staff.

The practice is a training practice for second year Foundation Doctors (FY2), GP Registrars and medical students. A FY2 is a medical practitioner undertaking a Foundation Programme which forms the bridge between medical school and specialist training. GP Registrars are fully qualified doctors training to become a GP through a period of working and training at the practice.

The practice is classed as being in one of the lesser deprived areas of Leeds.

All three sites are situated in purpose building buildings with car parking available.

When the practice is closed out-of-hours services are provided by Local Care Direct, which can be accessed via the surgery telephone number or by calling the NHS 111 service.

Updated 5 December 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Windsor Group Practice on 22 June 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• 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. Improvements were made to the quality of care as a result of complaints and concerns.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 5 December 2016

The practice is rated as good for the care of people with long-term conditions.

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
• Outcomes for diabetes related indicators were comparable or better than other practices. For example the percentage of patients on the register who had a flu immunisation in the preceding 12 months was 97% compared to the CCG and national averages of 94%.
• 93% of patients with diabetes, on the register, had a record of a foot examination and risk classification, compared to the CCG and national averages of 88%
• Longer appointments and home visits were available when needed.
• All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Updated 5 December 2016

The practice is rated as good for the care of families, children and young people.

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances. Immunisation rates were relatively high for all standard childhood immunisations.
• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.
• The percentage of eligible women, who had undergone a cervical screening test in the preceding five years, was 84% which was better than the CCG average of 79% and the national average of 82%.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• The practice held weekly baby clinics for six to eight week checks; in addition there was also a weekly immunisation clinic.
• Two GPs at the practice had expertise in family planning and provided postnatal services for women.
• The practice hosted a weekly clinic for patients aged 16 years and under, for young people to access clinical advice.
• At the time of our inspection the practice were in the process of developing an in-house long-acting reversible contraceptive service (LARC). LARCs are methods of birth control such as injections and contraceptive implants.
• We saw positive examples of joint working with midwives, health visitors and school nurses.

Updated 5 December 2016

The practice is rated as good for the care of older people.

• The practice offered proactive, personalised care to meet the needs of the older people in its population.
• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
• All patients aged 75 and over had a named GP.
• The practice was involved in the care homes scheme. This involved a GP visiting each of the care homes on a weekly basis to provide regular clinical reviews for patients.

Updated 5 December 2016

The practice is rated as good for the care of working-age people (including those recently retired and students).

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
• The practice hosted the locality urgent care service on a Saturday morning and patients from the practice as well as those patients registered at other practices were able to access this service. In addition, at the time of our inspection the practice were in the process of implementing extended hours to provide an 8am to 8pm service across all three sites.
• The practice was proactive in offering online services including appointment booking, as well as a full range of health promotion and screening that reflects the needs for this age group.
• The practice were part of a job retention pilot which provided support to people of working age who had difficulties retaining employment. This was to support patients who were currently employed, but off work due to mental health problems, to return to work.

Updated 5 December 2016

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
• The practice carried out advance care planning for patients with dementia.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
• The practice had a system in place to ensure follow up consultations had taken place for patients suffering with depression. If a follow up had not taken place then the practice proactively contacted the patient to arrange a review.
• Staff had a good understanding of how to support patients with mental health needs and dementia.
• 85% of patients diagnosed with dementia had received a face to face review of their care in the last 12 months, which is comparable to the CCG average of 83% and national average of 84%.

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
• The practice carried out advance care planning for patients with dementia.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
• The practice had a system in place to ensure follow up consultations had taken place for patients suffering with depression. If a follow up had not taken place then the practice proactively contacted the patient to arrange a review.
• Staff had a good understanding of how to support patients with mental health needs and dementia.
• 85% of patients diagnosed with dementia had received a face to face review of their care in the last 12 months, which is comparable to the CCG average of 83% and national average of 84%.

Updated 5 December 2016

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

• The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
• The practice had a lead GP and lead nurse to support patients with a learning disability and offered longer appointments to accommodate these patients.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients.
• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.
• The practice had two nominated safeguarding leads. Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.
• The practice had a nominated GP lead for the drugs of misuse register; this role involved monitoring patients who could be misusing drugs or prescribed medication.
• The practice had access to telephone interpreter services and liaised with the Leeds Asylum Seekers Support Network (a charity organisation providing support for refugees and asylum seekers in Leeds).