The Care Quality Commission
  • Doctor
  • GP practice

Edlesborough Surgery

Overall: Good read more about inspection ratings

11 Cow Lane, Edlesborough, Dunstable, Bedfordshire, LU6 2HT (01525) 221630

Provided and run by:
Edlesborough Surgery

Important: The provider of this service changed - see old profile

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Edlesborough Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Edlesborough Surgery, you can give feedback on this service.

2 September 2022

During an inspection looking at part of the service

We carried out an announced inspection at Edlesborough Surgery on 2 September 2022. Overall, the practice is rated as Good.

  • Safe - Good
  • Effective - Good
  • Caring - Good (rating awarded at the 2017 inspection)
  • Responsive - Good (rating awarded at the 2017 inspection)
  • Well-led - Good

Following our previous inspection in January 2017, the practice was rated Good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Edlesborough Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection, the practice was selected at random, from a selection of services rated Good and Outstanding to test the reliability of our new monitoring approach which involved a site visit.

We looked at the Safe, Effective and Well-led key questions.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews including interviews using video conferencing facilities
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A site visit to Edlesborough Surgery
  • Observations of the dispensary at Edlesborough Surgery
  • Discussions with patients, practice staff and the patient participation group.

Our findings

We based our judgement of 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.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm and there was active and appropriate engagement in local safeguarding processes.
  • Patients received effective care and treatment that met their needs. We reviewed patient consultation records and found examples of appropriate clinical interventions, monitoring, prescribing and coding.
  • Personal development and learning was actively promoted and a wide range of learning opportunities were provided for staff of all grades and disciplines.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • There was an established network of internal meetings to share information, assist with planning, and review any emerging concerns or new workstreams.
  • The practice had a proactive approach to seeking out and embedding new and more sustainable models of primary care, this included work to become a ‘Green Practice’ and become a more environmentally friendly.

We saw two areas of outstanding practice:

  • One of the GPs had worked alongside the reception team and created a ‘traffic light’ signposting tool to enable reception staff to identify deteriorating or acutely unwell patients. The tool also supported reception to signpost other clinical presentations to the most appropriate service. This tool aligned to the training the reception team had received to recognise medical emergencies which included a module on how to spot suspected sepsis. Within a week of the launch of the tool and completed training, one of the reception team had correctly recognised the presentation of sepsis and summoned emergency help. Sepsis is a life-threatening reaction to an infection.
  • In April 2022, the practice installed an automated prescription dispensing machine, located at the Edlesborough practice. Staff were asked to name the machine and agreed to name the machine ‘Spenser’. Dispensary staff prepared the prescriptions, bagged and labelled the prescribed items as normal, then loaded ‘Spenser’ (the machine). At the point an individual bag was loaded, the patient was contacted via secure message to tell them their medicines were ready for collection. The message contained a unique six-digit code and information on how long the patients had to pick up their prescription. Using the touchscreen built into the machine, the patient then entered their PIN code, made payment (where required) and then received their bagged prescription. Both staff feedback and patient feedback was overwhelmingly positive, dispensary staff advised ‘…it felt like an extra pair of hands…’ whilst patient feedback highlighted the efficiency of the machine. We saw data which indicated between one recent Friday evening and Monday morning, 60 different patients had collected their medicines, this would not have been possible without the machine. Given the success and positive feedback from the dispensary staff and patients, the practice was looking to install a similar machine at the branch practice in Pitstone.

Whilst we found no breaches of regulations, the provider should:

  • Revise the format of the medication reviews, thus ensuring the reviews are structured and include additional detail.
  • Review and seek to improve the process for staff to follow to help raise any concerns, this includes promotion of the Freedom to Speak Up Guardian.

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

Dr Sean O’Kelly

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

25 January 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

Our previous comprehensive inspection at Edlesborough Surgery on 23 June 2016 found breaches of regulations relating to the safe, effective and well-led delivery of services. The overall rating for the practice was requires improvement. Specifically, we found the practice to require improvement for provision of safe, effective and well led services. It was good for providing caring and responsive services. Consequently we rated all population groups as requires improvement. The full comprehensive report on the June 2016 inspection can be found by selecting the ‘all reports’ link for Edlesborough Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 25 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 23 June 2016. This report covers our findings in relation to those requirements and improvements made since our last inspection.

We found the practice had made improvements since our last inspection. At our inspection on the 25 January 2017 we found the practice was meeting the regulations that had previously been breached. We have amended the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective, caring, responsive and well led services. Overall the practice is now rated as good. Consequently we have rated all population groups as good.

Our key findings were as follows:

  • The practice had introduced regular dispensing audits and implemented stock control system.
  • There was an effective system in place for reporting and recording dispensing related incidents and significant events.
  • Blank prescription forms and pads were kept securely and tracked through the practice.
  • All staff who acted as a chaperone had received a Disclosure and Barring Service (DBS) checks and emergency procedures were reviewed to keep patients safe and safeguarded from abuse.
  • The practice had demonstrated significant improvements in patients’ outcomes for patients with dementia, learning disabilities and patients experiencing poor mental health.
  • We saw the childhood immunisation rates for the vaccines given to under two year olds were 94%. The practice informed us that low figures during previous inspection in June 2016 were due to a clerical error.
  • For example, performance for dementia face to face review had increased from 77% to 94%, compared to the previous inspection.
  • The practice had installed a hearing induction loop at reception.
  • The practice had displayed information about a translation service in the waiting area.
  • Staff we spoke with on the day of inspection was aware about a translation service.
  • The practice had demonstrated significant improvements in governance arrangements.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

23 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Edlesborough Surgery on 23 June 2016. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for provision of safe, effective and well led services. It was good for providing caring and responsive services.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and the practice had investigated significant events and implementing change was clearly planned in some areas with the exception of those related to dispensing incidents. The practice had not always investigated the dispensing related incidents thoroughly and lessons learned were not always communicated widely enough to support improvement.
  • The majority of information about safety was recorded, monitored and reviewed.
  • Risks to patients and staff were assessed and well managed in some areas, with the exception of those relating to management of blank prescriptions, dispensing audits and rolling stock checks, emergency procedures to deal with emergencies and Disclosure and Barring Scheme (DBS) checks or risk assessment for non-clinical staff undertaking chaperoning duties.
  • Data showed patient outcomes were mostly above the national average. However, the practice was required to improve outcomes for patients on the learning disabilities register, patients with dementia and patients experiencing poor mental health.
  • We found that completed clinical audits cycles were driving positive outcomes for patients.
  • Staff assessed patients’ needs and delivered care in line with current evidence based 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 they were involved in their care and decisions about their treatment.
  • Patients we spoke to on the day of inspection informed us they were able to make an appointment with a named GP, with urgent appointments available the same day.
  • Information about services and how to complain were available and easy to understand. However, information about a translation service was not displayed in the reception areas informing patients this service was available.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Anti-coagulation clinic (An anti-coagulant is a medicine that stops blood from clotting) was offered onsite, meaning 97 patients who required this service did not have to travel to local hospitals.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

  • Review the process for investigating and implementing change following dispensing related incidents and establish a programme of systematic dispensing audits and rolling stock checks against defined criteria.
  • Ensure there is a Disclosure and Barring Scheme (DBS) check based on a risk assessment for all non-clinical staff undertaking chaperoning duties.
  • Review the management and security of blank prescription forms, to ensure this is in accordance with national guidance.
  • Review protocols and risks associated with the current arrangements for emergency procedures to ensure staff could access these if required. Ensure there is a mercury spill kit in place.
  • Review and improve the systems in place to effectively monitor and improve patient outcomes for patients on the learning disabilities register, patients with dementia, childhood immunisation rates for under two year olds and patients experiencing poor mental health.
  • Further review, assess and monitor the governance arrangements in place to ensure the delivery of safe and effective services.

The areas where the provider should make improvements are:

  • Consider installing a hearing induction loop at reception.
  • Ensure all staff are aware that a translation service is available and information about a translation service is displayed in the reception areas.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice