• Doctor
  • GP practice

Bellbrooke Surgery

Overall: Good read more about inspection ratings

Bellbrooke Avenue, Leeds, West Yorkshire, LS9 6AU 0844 477 2502

Provided and run by:
Bellbrooke Surgery

Latest inspection summary

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Background to this inspection

Updated 23 January 2020

On the day of inspection, we visited Bellbrooke Surgery, Bellbrooke Avenue, Leeds LS9 6AU, which is located within the Harehills district on the outskirts of Leeds. The purpose-built premises are leased by the GP partners. There is a main reception area as you enter the premises with additional patient waiting areas downstairs and on the first floor of the building; accessible by a lift or stairs. CCTV is in operation and monitored by reception and administration staff. There are consulting and treatment rooms on both floors. There is onsite parking and disabled access.

Bellbrooke Surgery 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. The practice provides services to approximately 14,500 patients under the terms of a locally agreed NHS Personal Medical Services (PMS) contract.

The patient population consists of 48% white British and 52% from black and minority ethnic backgrounds; incorporating approximately 82 different languages. The practice reports a high migrant population, compared to many other Leeds practices, and can evidence a 10% turnover of patients in the preceding 12 months, through monthly audits. This consistently proves challenging for the practice in terms of capacity, demand, access and patient communication.

The National General Practice Profile shows the level of deprivation within the practice demographics as being rated one. (This is based on a scale of one to ten, with one representing the highest level of deprivation.

There are patient demographic variables compared to the local CCG averages, for example:

  • 58.5% of patients are under 18 years of age (CCG 38.2%)
  • 12.2% of patients are aged 65 years and over (CCG 24.1%)
  • 19.4% of patients are classed as unemployed (CCG 5.3%)
  • Prevalence of smoking is 34.2% (CCG 20.1%)

The practice clinical team consists of six GP partners (one male, five female), five salaried GPs (one male, four female), one practice matron, three practice nurses and four healthcare assistants (all of whom are female). The non-clinical team consists of a practice manager, an operational manager and a range of reception, secretarial and administration staff.

The practice opening hours are 8am to 6pm Monday to Friday, with in-house extended hours access until 8pm on Monday and Wednesday. Patients also have access to extended evening and weekend appointments via a local “hub” of practices.

The practice provides a training environment for GP registrars, student nurses, student pharmacists and student physician associates. They also support workplace experiences for students from the Leeds university and college.

The provider of the service is registered with CQC to deliver the regulated activities: diagnostic and screening procedures, treatment of disease, disorder or injury, maternity and midwifery services, family planning and surgical procedures.

The previous inspection ratings were displayed both in the practice and on their website.

Overall inspection

Good

Updated 23 January 2020

We carried out an inspection of this service due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions:

  • are services effective
  • 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 services safe
  • are services responsive
  • are services caring

We based our judgement on 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 and good for all population groups; with the exception of families, children and young people and working age people (including those recently retired and students), which were rated as being requires improvement.

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 supported with training and development 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.
  • There was a range of risk assessments, data analysis, audits and reviews to support quality improvement. Any areas for improvement were identified and acted upon.
  • Staff were committed to providing high-quality, accessible services.
  • Patients received structured reviews of their care and treatment. They received appropriate care and advice to support management of their symptoms and were signposted to other avenues of support as appropriate.
  • The practice was proactive in the development of the local primary care network to support the provision of services for their community.
  • Patient comments we received on the day of inspection were generally positive about the practice and the service they received.

The areas where the provider should make improvements are:

  • Review fire evacuation processes to support patients with mobility difficulties in navigating the stairs in the event of a fire.
  • Continue to monitor exception reporting for the Quality and Outcomes Framework
  • Continue to monitor and improve the uptake rates for childhood immunisations.
  • Continue to monitor and improve the uptake rates for cancer screening.

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

Dr Rosie Benneyworth BM BS MDedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care