The Care Quality Commission
  • Doctor
  • GP practice

Wheatfield Surgery

Overall: Requires improvement read more about inspection ratings

60 Wheatfield Road, Lewsey Farm, Luton, Bedfordshire, LU4 0TR (01582) 601116

Provided and run by:
Wheatfield Surgery

All Inspections

28 September 2021

During a routine inspection

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

25 Feb 2020

During an inspection looking at part of the service

We carried out an announced focused inspection at Wheatfield Road Surgery on 25 February 2020. This inspection was undertaken to confirm that the practice had carried out their plan to meet the legal requirements regarding the breaches in regulation set out in warning notices we issued to the provider in relation to Regulation 12 Safe care and treatment.

At the last inspection in August 2019 we rated the practice as requires improvement overall. This will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the initial report.

The full comprehensive report from the August 2019 inspection can be found by selecting the ‘all reports’ link for Wheatfield Road Surgery on our website at .

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.

Our Key findings:

  • The practice had complied with the warning notices we issued and had taken the action needed to comply with the legal requirements.
  • We found that patients who were treated with medicines that required additional monitoring had received the appropriate blood tests prior to prescribing.
  • Systems were in place to manage patient safety alerts. Records we checked showed that these were actioned appropriately.
  • Patient Group Directions (PGDs) had been appropriately signed by the nursing team and authorised by an appropriate person. (PGD’s allow non-prescribing practitioners to give medicines, including vaccinations, without a prescription.)
  • We saw that recommended actions from the legionella risk assessment were being completed and the practice was conducting regular water temperature checks and outlet flushing.
  • We saw that the training needs of staff were assessed. All staff had received the appropriate level of basic life support and safeguarding training.
  • The practice had implemented systems of checking consultation rooms to ensure that single use equipment, such as dressings, were within date.

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

07 Aug 2019

During a routine inspection

We carried out an announced comprehensive inspection at Wheatfield Road Surgery on 07 August 2019. We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

At the last inspection in March 2016 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 medicines that required additional monitoring was ineffective and blood testing was not completed within the recommended timeframes.
  • The practice had a process in place to manage safety alerts however, we saw evidence of one alert that had not been acted on. Shortly following the inspection, we received evidence that the process had been reviewed.
  • Clinical staff were not all trained to the appropriate level in adult or children’s safeguarding. However, staff were able to explain their role in safeguarding including how to recognise abuse and how to escalate concerns
  • The practice had completed a legionella risk assessment however, remedial actions that had been identified to mitigate the risk of legionella had not been completed.
  • Patient Group Directions that ensure vaccinations are given appropriately by the nursing team had not been signed by the necessary clinical staff.

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

  • Exception reporting was high in some areas, particularly within long term conditions. The practice was not pro-active in following up these patients.
  • Child immunisation rates were lower than WHO targets of 90%
  • There were gaps in the training of some staff members.

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

  • Patients told us they were treated with kindness and compassion.
  • The practice had identified 1.5% of their practice population as carers and had appropriate resources in place to support carers.

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

  • GP patient survey results for responsive indicators were below the local and national averages however, the practice had completed a patient satisfaction project and recently restructured their appointment system.
  • Patients told us that there was difficulty accessing the practice via the telephone. The practice was in the process of creating an action plan to address this concern.
  • Complaints were managed in an effective and timely manner however; response letters did not always contain information of how to escalate concerns to the parliamentary and health service ombudsman.

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

  • The practice had not identified that medicines that requires monitoring were not appropriately managed despite using a monthly reporting tool.
  • The practice did not have full oversight of actions that needed completing following risk assessments.

The areas where the provider should make improvements are:

  • Continue to review the dressings and single-use equipment that is stored in GP consultation rooms to ensure this remains in-date.

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

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


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

16 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Wheatfield Surgery on 16 February 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 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.
  • Information about services and how to complain was available and easy to understand.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • 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.

We saw one area of outstanding practice:

  • The practice identified patients who were also carers and placed an alert on the electronic patient record. A member of the reception team was the carers’ lead. There was a carers’ corner in the waiting area where written information was available to direct carers to the various avenues of support available to them. This area was surrounded by a partition which provided privacy for patients if they needed to access the information or complete any forms.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice