Background to this inspection
Updated
11 December 2018
Colton Mill Medical Centre is registered with CQC to provide primary care services. Regulated activities which includes access to GPs, family planning, surgical procedures, treatment of disease, disorder or injury and diagnostic and screening procedures. It provides GP services for patients living in the Colton area of Leeds.
Main Site - Stile Hill Way, Colton, Leeds, West Yorkshire, LS15 9JH.
Branch Site - 999 York Road, Seacroft, Leeds, West Yorkshire, LS14 6NX.
Website: www.coltonmill-thegrange.nhs.uk
A branch surgery ‘The Grange Medical Centre’ also provides the same services (apart from minor surgery) in the Seacroft area of Leeds and was also visited as part of this inspection. The two sites had a single patient list, so patients could be seen at either site depending on what was more convenient for them.
The practice had five GP partners (three male, two female), two salaried GPs, two associate GPs, a management team, four practice nurses, two healthcare assistants, 16 administrative staff, two senior pharmacists and cleaning staff.
The practice main site was open 8am to 6pm on Monday to Friday; the branch site was open 8am to 8pm on Wednesday and 8am to 8:30pm on Thursday. On a weekend the service was available from 8am to 12pm at alternate locations.
Patients could book appointments in person, via the phone and online.
Appointments could be booked up to a week in advance for the doctors and a month in advance for the nursing clinics. When the practice was closed patients accessed the out of hours NHS 111 service.
The practice was part of NHS Leeds CCG. It was responsible for providing primary care services to 12,909 patients. The female patient population of the practice makes up 51% of the practice population and 21% of all patients are over 60 years of age. The practice was
meeting the needs of an increasingly elderly patient list size that is generally comprised of more women than men.
When we returned to the practice for this inspection, we checked, and saw that the previously awarded ratings were displayed, as required, in both the practice premises. The overall rating was displayed on the practice website with a link to the inspection report.
Updated
11 December 2018
This practice is rated as Good overall. (Previous rating October 2014 - Good)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Good
We carried out an announced comprehensive inspection at of Colton Mill and The Grange Medical Centres on 30 October 2018 as part of our inspection programme.
At this inspection we found:
- The practice ensured clinical support arrangements were recorded, these records were documented formally.
- Management of significant events were recorded so that trends could be identified. We saw that the provider recognised and acted on significant events. When incidents did happen, the practice learned from them and improved their processes.
- All patients on high risk medicines had been reviewed in a timely manner and emergency medicines expiry dates were monitored.
- Safeguarding systems had been implemented to ensure relevant information was placed on patients records to alert clinicians when a child was subject to any part of the child protection process.
- A programme of clinical audits had been embedded in the practice to review the effectiveness of care and identify possible areas for improvement.
- The system for dealing with complaints was regularly monitored.
- There were regular clinical and team meetings and processes to improve communication in the practice.
- Patients said they were treated with dignity and trusted the staff.
- The provider had a good relationship with the wider multidisciplinary team members.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided and ensured that care and treatment was delivered according to evidence- based guidelines.
- The leadership team were effective and had a clear vision and purpose. There were systems in place to drive continuous improvement.
- The Patient Participation Group (PPG) engaged with patients during immunisation days and actively supported membership to include people from all backgrounds.
- The practice had developed a Measles outbreak action plan which was shared CCG wide.
- The practice has a dedicated self-check monitoring room which encouraged patient self-management. In the last year 350 patients had used this service. There was an electronic prescribing service for patients who had LTC (88% usage from primary care dashboard report July 18).
- Diabetes nurses were involved in co-producing the first peer review for diabetic foot screening due to high risks in the Leeds area. All nurses were trained on foot screening.
- The practice took part in the national diabetes prevention programme and the referral rates were the highest in Leeds for patients into the programme.
- The practice offered local training events for clinical staff led by lead nurse for respiratory and diabetes.
- The practice implemented the group consultation pilot as one of the locality innovations in Seacroft.
- The practice was the second highest user of ‘Leeds care record’ for accessing medical records for patients.
- The practice had developed a Measles outbreak action plan which was shared CCG wide.
The areas where the provider should make improvements are:
- Review and improve the processes in place for the cleaning and/or replacement of privacy curtains in line with the latest national infection prevention and control guidance.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice