We carried out an announced comprehensive inspection at Leighton Road Surgery on 20 February 2019 in response to concerns. Our inspection team was led by a CQC inspector and included a further CQC inspector, a GP specialist advisor and a practice nurse specialist advisor.

At the last inspection in March 2017 we rated the practice as good overall.

Our judgement of the quality of care at this service is based 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.

The practice is rated as requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

• The system to manage pathology results was ineffective and blood results were not being reviewed in a timely manner. The practice addressed this immediately following our inspection.
• We found out of date dressings in clinical rooms. This practice addressed this immediately.
• The system to ensure prescription stationery was appropriately managed was ineffective. We received evidence following the inspection that this system had been reviewed.
• Safety alerts were not appropriately managed and there was no oversight to ensure these had been actioned. We looked at recent safety alerts and some of these had not been appropriately actioned. The practice provided evidence shortly after our inspection to provide assurance that this has now been addressed.
• People who used the service were protected from avoidable harm and abuse.

We rated the practice as good for providing effective services because:

• There was evidence of regular reviews for patients with complex needs or long-term conditions.
• Childhood immunisation uptake rates were above the World Health Organisation (WHO) targets.
• Staff were appropriately inducted and supported with training needs.

We rated the practice as good for providing caring services because:

• Staff showed commitment to patient care and ensured their privacy and dignity was maintained at all times.
• The practice maintained a carers register and offered appropriate support to these patients.

We rated the practice as requires improvement for providing responsive services because:

• Patients told us they found accessing the practice by telephone was difficult.
• The GP National Survey results were below local and national averages.
• Complaints were appropriately responded to and analysed.
• The practice had responded to patient feedback and made improvements in relation to access, however, levels of patient satisfaction was still low.

We rated the practice as good for providing well-led services because:

• The leadership, governance and culture of the practice promoted the delivery of high quality person-centred care.
• Staff told us that they felt supported and that management teams were visible and responsive to concerns.
• Key policies were accessible to all staff.

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

• Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

• Continue to conduct appraisals for all staff groups.
• Continue to assess and improve patient satisfaction in relation to access.

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

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Leighton Road Surgery on 8 September and 11 October 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 an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Staff were aware of their responsibilities in helping to safeguard and protect patients and had undertaken specific training to support this, for example Female Genital Mutilation (FGM) training.
• Staff were aware of their responsibilities in helping to safeguard and protect patients and had undertaken specific training to support this.

• 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.
• They worked well with multidisciplinary teams, including community and social services to plan and implement care for their patients.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The practice held regular staff and clinical meetings where learning was shared from significant events and complaints.
• The practice held daily lunch time meetings for the clinical team to discuss cases and share learning.
• 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 offered extended hours appointments.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice hosted a number of community services which enabled patients to access services nearer home.
• 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.

There was one area where the practice should make improvements:

• The practice should continue to monitor the availability of appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice