Background to this inspection
Updated
29 March 2019
South Queen Street Medical Centre is located at South Queen Street, Morley, Leeds LS27 9EW. The premises are purpose-built and are owned by the GP partners. There is a small car parking area for staff and patients.
The provider is registered with the CQC to provide the following regulated activities: diagnostic and screening procedures; treatment of disease, disorder or injury; family planning; maternity and midwifery services; surgical procedures.
South Queen Street Medical Centre is situated within the Leeds Clinical Commissioning Group (CCG) and is part of a locality group of practices. The practice provides services to approximately 4,111 patients under the terms of a locally agreed NHS Personal Medical Services (PMS) contract. 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 patient population consists of approximately 95% of white ethnicity, with the remaining from mixed ethnic groups. There is an approximate equal ratio of male and female patients. The practice has close links with several local residential care homes, where registered patients reside.
The practice clinical team consists of one lead male GP who is supported by two female salaried GPs, a long-term female locum GP, a sessional advanced nurse practitioner, a practice nurse and a healthcare assistant. The non-clinical team consists of a practice manager, a finance manager and a range of administration and reception staff. There is another male GP partner who does not provide any clinical sessions. The lead GP has been advised to review their registration arrangements with the CQC with regards to the partnership.
Opening hours are Monday to Friday 8am to 6.30pm, with extended hours on Tuesday until 8.30pm. Patients can also access extended hours appointments seven days per week at various times via a local ‘hub’ based at Windsor House Surgery. There are out-of-hours services available for patients in case of emergencies via a locally agreed contract.
South Queen Street Medical Centre is accredited as a training practice and supports GPs in training, as well as medical, nursing and dental undergraduates.
Updated
29 March 2019
We carried out an announced focused follow-up inspection at South Queen Street Medical Centre on 19 March 2019 as part of our inspection programme.
At the last inspection on 19 July 2018 we rated the practice as good overall, with ratings of requires improvement for the domain of safe. At that time it was found the practice was in breach of Regulation 12 of the Health and Social Care Act (RA) Regulation 2014; safe care and treatment. The full comprehensive report regarding the July 2018 inspection can be found by selecting the ‘all reports’ link for South Queen Street Medical Centre on our website at
The practice was rated as requires improvement for providing safe services because:
- Oversight of medical indemnity status and the professional registration of clinicians was not maintained.
- Gaps in the immunity status records of clinical staff were not acted upon.
- Recruitment checks and training records for locum doctors were not consistently applied.
- Fire safety training was not undertaken on an annual basis in line with mandatory training guidance.
- Response letters to complainants did not include details of the Parliamentary and Health Service Ombudsman, should they wish to escalate their concerns.
- Cleaning records were not available in relation to clinical equipment.
At this inspection, we found that the provider had satisfactorily addressed all the areas of concern which had been raised at the previous inspection.
We based our judgement of the quality of care at this service using a combination of what we found when we inspected, information from our ongoing monitoring of data about services and
information from the provider, patients, public and other organisations.
We have now rated this practice as good overall and good for all population groups.
We found that:
- The medical indemnity status and professional registrations of all clinicians, including locums, were kept. We saw evidence that these were up-to-date.
- There was clearly recorded evidence of the immunisation status of clinical staff. The practice had engaged with the local occupational health department to support the checking of status and the provision of immunisations.
- The recruitment protocol had been reviewed to ensure that all checks prior to recruitment were applied. Training records were maintained for all staff, including locums.
- All staff had received fire safety training and this was to be undertaken on an annual basis.
- There was evidence of cleaning records regarding clinical equipment.
- Details of the Parliamentary and Health Service Ombudsman and the local Patient Advice and Liaison Service (PALS) were applied to each letter of response sent to complainants.
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