Background to this inspection
Updated
25 November 2021
Wheatfield Surgery is located in Bedfordshire at:
60 Wheatfield Road,
Lewsey Farm,
Luton,
Bedfordshire,
LU4 0TR.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning, treatment of disease, disorder or injury and surgical procedures.
The practice is situated within the NHS Bedfordshire, Luton and Milton Keynes Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of approximately 13,200 patients. There is a slightly higher than national average number of patients under the age of 18 years. According to the latest available data, the ethnic groups of the practice population consists of 74% white, 12% Asian, 9% black with the remaining of mixed or other ethnicity.
Information published by Public Health England rates the level of deprivation within the practice population group as four on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.
The practice is a training practice and employs GP registrars. A GP registrar is a fully qualified and registered doctor who is completing further training to become a GP.
The clinical team consists of six GP partners (two female / four male) and one salaried GP (female). The practice also employs a female advanced nurse practitioner, three female practice nurses, a clinical pharmacist and two female healthcare assistants. The team is supported by a practice manager and a team of administrative staff.
Wheatfield Surgery is a two-storey building where consultations take place on the ground floor. There are facilities for patients with a disability including designated parking.
The practice is open Monday to Friday from 8.30am to 6.30pm and provides extended opening hours between 6.30pm and 8.30pm. When the practice is closed patients are directed to the out of hours provider via the NHS 111 service. Patients also have access to the Extended GP Access Service between 6.30pm and 8pm on weekdays, 8.30am to 12pm on weekends, and on bank holidays.
Updated
25 November 2021
We carried out an announced inspection at Wheatfield Surgery on 28 September 2021. Overall, the practice is rated as requires improvement.
The ratings for each key question are:
Safe - Requires improvement
Effective - Requires improvement
Caring - Good
Responsive - Requires improvement
Well-led – Requires improvement
The practice was inspected on 7 August 2019 and rated requires improvement overall and for the key questions safe, effective, responsive and well-led but was rated good for providing caring services. Following the inspection, we took enforcement actions against the provider and issued a warning notice for breaches of Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014, Safe care and treatment.
We carried out an announced focused inspection at Wheatfield Road Surgery on 25 February 2020, to confirm that the practice had carried out their plan to meet the legal requirements regarding the breaches in regulation set out in the warning notice we issued to the provider. The practice had taken the action needed to comply with the legal requirements of the warning notice we issued.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Wheatfield Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive inspection which included a site visit to review all of the key questions and update the providers rating.
How we carried out the inspection/review
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 using video conferencing
- 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 short site visit.
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 and
- information from the provider, patients, the public and other organisations.
We have rated this practice as requires improvement overall and for providing safe, effective, responsive and well led services including all the population groups. We have rated the service as good for providing caring services.
- The practice did not have fully effective systems in place for the appropriate and safe use of medicines, this included regular monitoring arrangements for patients on high risk medicines. The practice was taking action to improve.
- Staff did not always have the information they needed to deliver safe care and treatment as the arrangements in place to manage workflow was not comprehensive.
- There was a lack of a consistent approach to the management of patients care and treatment. The practice continues to perform below national averages for cancer screening and the uptake of childhood immunisations.
- People were not always able to access care and treatment in a timely way. The results of the recent national GP survey showed the practice was below the local and national averages for questions relating to access. The practice was taking action to improve access and patients experience of the service.
- Systems and processes were not always embedded to ensure risks were assessed and managed. Areas for improvement had not been progressed or sustained.
- There were effective systems and processes in place for recruitment and infection prevention and control.
- Staff were provided opportunities for training and development with access to appraisals, one to one and clinical supervision. There was a high completion rate for staff training
- The results of the recent national GP survey showed the practice was mostly similar to the local and national average in questions relating to caring.
We found breaches of regulations. The provider must:
- Ensure that care and treatment is provided in a safe way.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The areas where the provider should make improvements are:
- Implement comprehensive quality assurance systems to demonstrate the competency of staff undertaking extended roles.
- Review Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions to ensure they are recorded and reviewed in line with relevant legislation.
- Continue to promote and explore ways to improve the identification of carers.
- Continue to monitor and take action to improve access and patients experience of the service.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care