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

This practice is rated as good overall. (Previous rating 29 July 2016 – Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced/unannounced comprehensive inspection at South Queen Street Medical Centre on 19 July 2018, as part of our inspection programme.

At this inspection we found:

• The practice had a range of systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements as they are in breach of regulations are:

• The provider must provide care and treatment in a safe way for service users

The areas where the provider should make improvements are:

• The provider should take steps to resolve their partnership registration with CQC to be assured that their registration accurately reflects their current legal entity.
• The provider should initiate cleaning logs for clinical equipment to be assured that there is an audit trail for this activity.
• The provider should maintain appropriate training records for all staff including locums.
• The provider should review and improve their complaints procedure to be assured that patients are consistently advised of their right to refer their complaint to the Parliamentary and Health Service Ombudsman should they be dissatisfied with the provider’s written response.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Drs. Hicks and McPeake on Wednesday 4 May, 2016. Overall the practice is rated as Good.

Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety, and a system in place for reporting and recording significant events.
• Risks to patients were managed, when identified.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a leadership structure and staff felt supported by management. The practice proactively sought feedback from patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.
• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients. Examples of this included a text messaging service informing patients of their test results and what action to take, and a system developed to ensure patients had a joint management care plan.

We saw the following area of outstanding practice:-

• Patients had been offered smoking cessation advice and it was noted that over 95% of patients who smoked and were over 16 years of age had been offered advice on how to stop smoking. Over 70% of patients with a BMI of 30+ had been offered weight management support.

However there are areas where the provider needs to make improvements.

The provider must:

• Provide, monitor and maintain oxygen supplies within the practice to enable staff to respond urgently in the event of a patient becoming seriously ill.

• Ensure that patient group directions (PGDs) are signed and updated appropriately. PGDs allow nurses to administer medicines in line with legislation.

• Develop systems of producing patient specific directions (PSDs) to enable health care assistants (HCAs) to administer vaccinations to a named patient when a doctor or nurse was on the premises.

In addition the provider should:

• Revise and update its locum pack to make it more comprehensive and informative. Evidence was provided within five working days of the inspection that this had been done.

• Review the communication arrangements within the practice to enable staff to share lessons learned from significant events and complaints.

• Develop systems to update patient care plans following multidisciplinary meetings.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Our inspection on 10 December 2013 found the provider did not encourage patients to express their views about how the service was run and what was important to them. The provider did not have effective recruitment procedures in place to ensure appropriate checks were carried out and there were issues identified with how the provider handled complaints.

At this inspection we found the provider had reviewed their policies and procedures and improvements had been made.

We saw that steps had been taken to ensure people's privacy was respected. However, the provider did not have effective methods to encourage patient feedback. There were no comments and suggestions boxes in the reception area and no Patient Reference Group had been established.

We spoke with five patients during our inspection who were happy with the service. Comments included:

“They are absolutely brilliant here. It’s very personal care.”

“There’s no problem getting appointments.”

“They are really good doctors.”

We saw the practice had adopted the West Yorkshire Safeguarding policies for adults and children. However the provider may find it useful to note that there was no internal policy in place. This meant that staff may be unsure of how to escalate concerns in the first instance.

The practice did not have effective recruitment procedures in place to ensure relevant information was obtained prior to employing new members of staff.

The system for managing and handling complaints was not effective. We saw that complaints were not recorded appropriately and saw evidence the complaints procedure had not been followed.