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We are carrying out a review of quality at Leighton Road Surgery. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 11 September 2019

We carried out an unannounced comprehensive inspection at Leighton Road surgery on 10 July 2019 in response to concerns. Our inspection team was led by a CQC inspector and included an inspection manager, a GP specialist advisor and a practice manager specialist advisor.

Following our last inspection in February 2019, the practice was rated as requires improvement overall.

The full comprehensive report from the February 2019 inspection can be found by selecting the ‘all reports’ link for Leighton 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.

We have rated this practice as inadequate overall and inadequate for all population groups. This was linked to findings around a lack of insight and capacity amongst leadership teams.

We rated the practice as inadequate for providing safe services because:

  • Medicine and safety alerts were not appropriately managed and there was no oversight to ensure these had been actioned. Records we reviewed confirmed no action had been taken in response to recent alerts.
  • Medicines that required additional monitoring were not appropriately managed and we saw patients had not received blood tests within the recommended time frames.
  • Vaccination fridges, emergency medicines and clinical waste were stored in patient accessible areas, compromising safety.
  • Cleaning logs of rooms and multiple-use equipment were not maintained.
  • Pathology results were reviewed in a timely manner however, appropriate action was not always taken.

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

  • We saw evidence of a lack of clinical oversight and clinical systems to ensure patients were appropriately entered onto disease registers.
  • Patients with long-term conditions were not consistently reviewed as appropriate.
  • Patients with a diagnosis of diabetes, or a possible diagnosis of diabetes, were not followed up following repeated abnormal blood results.
  • Patients were not consistently followed up when letters were sent, or they did not attend appointments.
  • Patients were not appropriately coded within patient records and we saw examples of where patients had been exception reported inappropriately.
  • Staff referred patients to secondary care and local resources as appropriate.
  • Care was co-ordinated with community providers through regular meetings.

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

  • GP patient survey results were below local and national averages. These indicators had further deteriorated in the 2019 survey, which were published shortly after this inspection.
  • The practice had not developed an action plan to improve patient satisfaction since the 2018 survey.
  • Patients told us they were treated with care and compassion.
  • The practice had identified approximately 2% of the population as carers.

We rated the practice as inadequate for providing responsive services because:

  • Patients told us they experienced difficulties accessing the practice via the telephone and making routine appointments.
  • Patients told us they suffered delays in obtaining repeat prescriptions for their medicines due to delays in obtaining appointments where they were required to see a GP.
  • GP patient survey results were lower than local and national averages and had deteriorated since the 2018 survey. The practice did not have an action plan to address these indicators.
  • The practice had not conducted any patient feedback exercises such as surveys to seek patients views for the purpose of evaluating and improving services for patients.

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

  • The practice had faced challenges with GP availability however there was no effective systems to mitigate this risk and ensure patient safety.
  • We saw that clinical capacity had decreased; however, the practice had not conducted any quality improvement activity or action plans to address this and mitigate the risk. The reduction in clinical capacity had resulted in a lack of clinical oversight.

  • Staff told us they had informed management of their concerns regarding appointment availability and clinical capacity however, these had not been acted on.

  • We were told that the practice had recruited further locum GPs and minor illness nurses; however, these were not in post at the time of inspection.
  • The practice was not able to evidence succession planning.
  • Risks to patient safety were not appropriately managed including management of safety alerts, management of patients with long term conditions, patients prescribed high risk medicines, emergency medicines and sharps waste.

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

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

Inspection areas


Requires improvement
Checks on specific services

People with long term conditions


Families, children and young people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable