Leighton Road Surgery

Updated 8 November 2021

Leighton Road Medical Centre is located in Leighton Buzzard at:

1 Leighton Road

Linslade

Leighton Buzzard

Bedfordshire

LU71LB

The practice has a branch surgery at:

Grovebury Road Surgery

Unit 6,7,8 Ridgeway Court,

Grovebury Road

Leighton Buzzard

Bedfordshire

LU7 4SF

Although Grovebury Road Surgery is registered as the branch site all patients were seen there with the exception of those undergoing minor surgical procedures which were undertaken at the practice’s main site. The Leighton Road Surgery main site also hosted other services including ultrasound and out of hours services. During the inspection we visited both sites.

Since 2019 the practice merged with East London NHS Foundation Trust (ELFT) who provide management and clinical support to the practice through their primary care directorate. ELFT also provide support to several other practices in East London and Bedfordshire.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, surgical procedures and treatment of disease, disorder or injury.

The practice did not have a registered manager and was not registered for the regulated activity of maternity and midwifery services. These issues were discussed with the provider who advised that they were addressing them.

The practice is part of the NHS Bedfordshire, Luton and Milton Keynes Clinical Commissioning Group (CCG) and delivers a General Medical Services (GMS), this is a nationally agreed contract with NHS England, to a patient population of approximately 20,000.

The practice is part of a wider network of GP practices through the Leighton Buzzard Primary Care Network. A primary care network (PCN) is a group of GP practices working together to address local priorities in patient care.

Information published by Public Health England shows that deprivation within the practice population group as nine on a scale of one to ten. Level one represents the highest level of deprivation and level ten the lowest.

According to the latest available data, the ethnic make-up of the practice area is 95% white.

Clinical staffing consists of four salaried GPs and ten locum doctors, three pharmacists (all independent prescribers), eight nurses (including minor illness nurses and a complex care matron), and four Healthcare Assistants. Non-clinical staff include a practice manager and a team of reception and administrative staff.

The practice is registered as a partnership of two directors from the East London NHS Foundation Trust who provide direct leadership support to practice staff.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.

Leighton Road Surgery (main site) is open 8am to 5.30pm Monday to Friday. There is a Saturday morning surgery one Saturday every four weeks between 8am and 2pm.

Grovebury Road Surgery (branch site) is open 8am to 6pm Monday to Friday with extended opening until 8.30pm on a Tuesday evening and one Saturday per month.

When the practice is closed, out of hours services are accessed via the NHS 111 service.

Updated 8 November 2021

We carried out an announced inspection at Leighton Road Surgery on 8 October 2021. Overall, the practice is rated as good.

The ratings for each key question are as follows:

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 1 October 2020, the practice was rated Requires Improvement overall and for the effective, caring, responsive and well-led key questions and good for providing safe services:

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

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on the findings from our inspection in October 2020, this included: the low numbers of mental health care plans completed, low cervical screening uptake and low levels of patient satisfaction with the service identified in the national GP patient survey.

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 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 Good overall.

We found that:

• The practice had continued to make improvements to the service since our previous inspection, this was demonstrated through improvements in patient outcome measures and patient satisfaction.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm. Although we did identify some areas the practice should improve.
• Patients received effective care and treatment that met their needs. Our review of clinical records found appropriate care and treatment was being provided.
• The practice was able to show how they had sustained and in some cases improved performance with regards to patient outcome data for patients with long term conditions, despite the challenges of the pandemic.
• The practice had made improvements in relation to the provision of services for mental health patients in particular; integrated working with the community mental health teams helped to deliver improved physical and mental wellbeing for this group of patients.
• The practice was committed to delivering quality improvement, we saw various projects in place to improve services for the practice population including work with some of the practice’s most vulnerable patients.
• Staff were encouraged to learn and had opportunities to develop in their roles and responsibilities.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care. The results from the latest National GP Patient Survey showed significant improvements in the patient experience from previous years.
• 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, patient satisfaction in relation to access showed significant improvement since our previous inspection.
• Complaints were acted on appropriately and in a timely way and used to make changes to the services.
• The way the practice was led and managed promoted the delivery of high-quality, person-centred care. The views of staff and patients were actively sought to deliver improvements and opportunities for learning encouraged.
• Governance arrangements supported the delivery of safe and effective care. Staff felt valued and motivated to deliver a high-quality service and deliver a comprehensive programme of quality improvement.

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

• Identify all household members in the event of safeguarding concerns and ensure all staff are up to date with their safeguarding training relevant to their roles.
• Include checks against the NHS National Performers list when recruiting GPs.
• Implement regular fire drills and ensure staff are competent in the use of the evacuation chair.
• Implement systems to demonstrate the routine cleaning of clinical equipment.
• Review systems for monitoring patients prescribed high risk medicines to ensure test results and information required for effective prescribing are accurately recorded and that patients understand when to take their medicines.
• Improve systems for monitoring the competence of non-medical staff in extended roles For example, prescribing, consultations and coding and for monitoring role specific training.
• Improve uptake of cervical screening.

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