The Care Quality Commission
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  • 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

All Inspections

During an assessment under our new approach

Bellbrooke Surgery is an NHS GP practice which provides primary care services to patients in Leeds, West Yorkshire. The practice is registered with the Care Quality Commission to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, treatment of disease, disorder or injury, family planning and surgical procedures. The practice is situated within the NHS West Yorkshire Integrated Care Board (ICB) and delivers Personal Medical Services (PMS) to a patient population of approximately 15,000. The practice is part of Burmantofts, Harehills and Richmond Hill primary care network which is made up of 11 other GP practices. The patient population consists of 45% white British, 23% Asian and 32% from black and minority ethnic backgrounds. The practice reports a high migrant population, compared to many other Leeds practices. Information published by Public Health England shows that deprivation within the practice population group is ranked 1 (1-10, where 1 is most deprived and 10 is least deprived). The practice was previously inspected in October 2015 and rated good overall and in the key questions safe, effective, caring, responsive and well-led. A focused inspection of the key questions effective and well-led was undertaken in October 2019 in which the practice was rated good for providing a well-led service, and requires improvement for providing effective services. We carried out this assessment to review the practice performance in the key questions safe, effective and well led, and to follow up on concerns raised with us regarding the culture of the practice. Following this assessment, the practice is rated good overall and for the key questions effective and well-led. The practice is rated requires improvement for the key question safe as we identified a breach of regulation 12 (Safe care and treatment). We have asked the provider for an action plan in response to the concerns found at this assessment.

23/10/2019

During an inspection looking at part of the service

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

29 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bellbrooke Surgery on 29 October 2015. Overall the practice is rated as good for providing safe, effective, caring, responsive and well-led care for all of the population groups it serves.

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 was in place for reporting and recording significant events.

  • Risks to patients were assessed and well managed.

  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • Patients said they were treated with compassion, dignity and respect and were involved in care and decisions about their treatment.

  • Urgent appointments were available on the same day as requested.

  • The practice operated a booked access clinic every weekday from 10.30am to 1pm to enable patients access to a same day appointment with a GP.

  • The practice had good facilities and was well equipped to treat and meet the needs of patients.

  • The practice sought patient views on how improvements could be made to the service, through the use of patient surveys, the NHS Friends and Family Test and the patient participation group.

  • There was a clear leadership structure and staff were supported by management.

  • 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