Background to this inspection
Updated
21 February 2020
On the day of inspection, we visited The Dekeyser Group Practice, Fountain Medical Centre, Little Fountain Street, Morley, Leeds, West Yorkshire LS27 9EN. The premises are purpose-built and are leased by the GP partners. There is a main reception area, disabled access facilities and onsite parking. At the time of our inspection, there were building works taking place to improve the premises, which included additional consulting rooms on the ground floor. The administration team and staff who answered the telephone calls had recently been relocated to a room on the first floor, to support confidentiality.
The Dekeyser Group Practice is situated within Leeds Clinical Commissioning Group (CCG) and is a member of a federation of practices across Leeds. They are also part of a primary care network (PCN) of local practices who work together to improve services for their patient populations. One of the GP partners acts as the clinical director of the PCN.
The practice provides services to approximately 16,281 patients under the terms of a locally agreed NHS Personal Medical Services (PMS) contract. Approximately 5% of the patient population are from black minority ethnic groups, with the remaining 95% from white British or Eastern European origin.
The National General Practice Profile shows the level of deprivation within the practice demographics as being rated five. (This is based on a scale of one to ten, with one representing the highest level of deprivation.) The average life expectancy of patients in the practice is 79 years for men and 83 years for women (local average is 78 years and 82 years respectively.)
The practice clinical team consists of five GP partners (one female, four male), one male salaried GP, three advanced nurse practitioners, one lead nurse, four practice nurses, four healthcare assistants and one practice pharmacist (all of whom are female). We were informed that the practice had recruited two additional female salaried GPs and a female associate physician. At the time of our inspection, these members of staff had not yet commenced work at the practice.
The non-clinical team consists of a business manager, a senior clinical support administration team and a range of secretarial, reception and administration staff.
The practice opening hours are 7am to 6.30pm Monday to Friday. When the practice is closed patients are directed to NHS 111 services. Patients also have access to extended evening and weekend appointments via a local “hub” of practices.
The provider of the services is registered with CQC to deliver the regulated activities of diagnostic and screening procedures, treatment of disease, disorder or injury, family planning, maternity and midwifery services and surgical procedures.
In line with CQC regulation, the previous inspection ratings were displayed both in the practice and on the practice website.
Updated
21 February 2020
The Dekeyser Group Practice had previously been inspected on 20 October 2016, where it had been rated as good overall.
We carried out an announced focused inspection of The Dekeyser Group Practice on 8 January 2020, following our annual review of the information available to use, including information provided by the practice. This inspection focused on the following key questions:
- are services effective
- are services responsive
- are services well-led.
Because of the assurance received from our review of information, we carried forward the ratings for the following key questions:
- are service safe (good)
- are services caring (good).
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
- information from the provider, patients, the public and other organisations.
We have rated this practice as good overall. We have rated responsive and all population groups as being requires improvement because:
-Patient satisfaction regarding how easy it was to get through to someone at the practice on the telephone was significantly below local and national averages.
-Patient satisfaction regarding their experience of making an appointment was below the local and national averages.
-Patients’ comments on CQC comment cards aligned with the above.
We found that:
- There were effective and comprehensive systems and processes in place to support good governance of the practice.
- Staff were aware of their roles and responsibilities. They were encouraged and supported with training and development opportunities, suitable for their individual roles.
- There was evidence of effective leadership and management. Leaders and managers had a good understanding of the challenges they faced regarding the provision of primary care services for their patient population. Staff reported there had been a positive cultural change.
- There was a range of risk assessments, data analysis and audit to support quality improvement. Any identified areas for improvement were acted upon.
- Staff were committed to providing high-quality accessible services.
- Patient comments were mixed about the service. All were positive about the care they received, the premises and how staff communicated with them. However, some patients commented negatively regarding telephone access. We were informed of the difficulties the practice had encountered with the telephone system and the changes they had subsequently made.
- The practice had introduced initiatives to support older and vulnerable patients accessing the service at their point of need.
The areas where the provider should make improvements are:
- Continue to monitor telephone access and improve patient satisfaction regarding this issue.
- Improve the system for filing correspondence and test results which have been acted upon.
- Improve and reduce the exception reporting relating to the Quality and Outcome Framework mental health indicators, to support patient care.
Details of our findings and the evidence supporting our ratings are set out in the evidence table.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care