The Care Quality Commission
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  • GP practice

Archived: Leighton Road Surgery

Overall: Good read more about inspection ratings

1 Leighton Road, Linslade, Leighton Buzzard, Bedfordshire, LU7 1LB (01525) 372571

Provided and run by:
Leighton Road Surgery

Important: The provider of this service changed. See new profile

All Inspections

8 October 2021

During a routine inspection

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

01 October 2020

During a routine inspection

The service is rated as Requires improvement overall.

(previously rated as inadequate in July 2019)

We carried out an unannounced comprehensive inspection at Leighton Road Surgery on 10 July 2019. The overall rating for the practice was inadequate, it was placed into special measures and warning notices were issued. We carried out an announced follow up inspection on 20 November 2019 and found that the practice had made sufficient improvements and was compliant with the warning notices.

The full comprehensive report on the July 2019 and November 2019 inspections can be found by selecting the ‘all reports’ link for Leighton Road Surgery on our website at www.cqc.org.uk.

We took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering how we carried out this inspection. We therefore undertook some of the inspection processes remotely and spent less time on site. We conducted staff interviews on 29 September to 1 October 2020 and carried out a site visit on 30 September 2020.

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 rated the practice as good for providing safe services because:

  • People who used the service were protected from avoidable harm and abuse.
  • Medicine and safety alerts are appropriately managed and there was oversight to ensure these had been actioned. Records we reviewed confirmed action had been taken in response to recent alerts.
  • Medicines that required additional monitoring were appropriately managed and we saw patients had received blood tests within the recommended time frames. The practice had developed a Prescription Clerk team who ran monthly searches of clinical systems to ensure all relevant patients were identified and invited for appointments.
  • There was good oversight of pathology results and clinical practice.
  • The practice had conducted clinical competency assessments for all practitioners that fed into individual appraisals. Overall themes from these assessments were shared with all staff for discussion and improvement.
  • Systems for Infection Prevention and Control were effective and additional measures had been put in place to ensure patient safety during the COVID-19 pandemic.
  • The practice developed the COVID-19 ‘hot hub’ for the Leighton Buzzard locality. This was safely set up within 48 hours with a full standard operating procedure in place that included access criteria, personal protective equipment (PPE) and enhanced cleaning. (A ‘red hub’ is a modified unit used for all patients showing signs of COVID-19 in a particular area needing to be seen by a health care professional throughout the pandemic.)

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

  • The population groups of working age patients and patients experiencing poor mental health have been rated requires improvement due to low clinical indicators regarding completion of mental health care plans and low cervical screening uptake. However, the other population groups have been rated good because patients were able to access effective services.
  • Patients with long-term conditions were reviewed as appropriate. Records we looked at showed that patients were treated in line with national guidance.
  • Patients with a diagnosis of diabetes, or a possible diagnosis of diabetes, were reviewed following abnormal blood results.
  • Staff referred patients to secondary care and local resources as appropriate.
  • The practice held a health fair where 26 stalls were set up to provide information on local health, fitness, volunteer and support initiatives. Approximately 400 people from the local population attended. The practice received positive feedback from the community.
  • Care was co-ordinated with community providers through twice weekly meetings.
  • The practice had a thorough system of audits that were shared with staff and used to drive practice improvements.
  • Staff were supported through monthly supervision meetings to access training and increase their skills.

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

  • The practice had taken action to address the GP Survey results that were below local and national averages, however, survey results had declined further.
  • Patients told us they were treated with care and compassion.
  • Staff we spoke with showed a strong commitment to patient care.
  • The practice had identified approximately 2% of the population as carers and offered appropriate support.
  • The practice offered extensive support to isolated patients within the COVID-19 pandemic where they telephoned all vulnerable or shielding patients each month. Support for these patients was personalised with staff organising medicines deliveries, food packages and befriending services. This process also enabled them to identify patients who needed further referrals, for example, to safeguarding teams. The practice was using the lessons learnt from the COVID-19 pandemic to influence the winter planning and flu vaccination programme where they were focusing on these vulnerable patients and ensuring they were vaccinated safely and efficiently.

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

  • Results from the GP Patient survey were below local and national averages, although many of these indicators had improved since the 2018 survey. The practice had action plans in place to address these indicators.
  • The practice had increased their clinical team and number of appointments offered. They had plans to further increase their clinical team by February 2021.
  • Patient feedback had improved since the last inspection, however, some patients told us they were still experiencing difficulties accessing appointments.
  • The practice had conducted several patient feedback exercises, such as surveys, to seek patients views for the purpose of evaluating and improving services for patients. They showed that patient satisfaction levels had improved.
  • The practice has identified that patients were struggling to manage prescriptions and access medicines efficiently. They had therefore set up a Prescription Clerk Team to support patients with prescription concerns. The team had a dedicated telephone line, consultation room and aligned GP.
  • Complaints were managed in a timely way and used to determine improvement activity.

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

  • Clinical indicators in some areas had deteriorated since the previous inspection. Plans to improve these indicators had yet to be embedded into practice and impact on patient outcomes.
  • Improvement plans regarding low GP patient survey results had not improved patient satisfaction.
  • The leadership, governance and culture of the practice promoted the delivery of high-quality person-centred care.
  • Staff told us that leaders were approachable and supportive. They were able to raise concerns and suggestions and confident this would be addressed.
  • Staff were proud to work at the practice and were supported with their personal and professional development.
  • The practice had a very active Patient Participation Group who were involved in all recruitment processes, process mapping and practice improvements.
  • The lead GP wrote a monthly column in the local newspaper to inform the public of the improvements at the practice. This article was also used to inform patients of local initiatives during the COVID-19 pandemic.
  • Risks to patient safety were appropriately managed including management of safety alerts, management of patients with long term conditions, patients prescribed high risk medicines and emergency medicines.
  • The practice involved patients in all processes within the practice. For example, patients were on all interview panels and process mapping meetings. We saw evidence that patient suggestions shaped and improved practice. For example, the pathology pathway had been altered to ensure that all communication following pathology results came from a clinician rather than an administrator.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

The areas where the provider should make improvements are:

  • Continue to improve cervical screening uptake.
  • Continue to improve the numbers of patients receiving mental health care planning.
  • Continue to improve GP patient survey results and patient satisfaction.

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

20 Nov 2019

During an inspection looking at part of the service

The service is rated as Inadequate overall.

We carried out an announced focused inspection at Leighton Road Surgery on 20 November 2019 to confirm that the practice had carried out the necessary improvements in relation to the breaches of regulation set out in warning notices we issued the provider. Warning notices related to regulation 12 Safe care and treatment and regulation 17 Good governance.

The practice received an overall rating of inadequate at our inspection on 10 July 2019 when warning notices were issued. This will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the initial report. An announced comprehensive inspection was also inspected in February 2019 as part of our regular inspection programme.

The full comprehensive report from the February 2019 and the July 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.

Our Key findings were as follows:

  • The practice had addressed the concerns raised and was compliant with the warning notices.
  • Pathology results were manged in an effective way and we saw evidence that abnormal results were followed up appropriately.
  • We saw that there was adequate oversight of patients with diabetes and those who may have a diagnosis of diabetes.
  • Patient safety alerts were adequately managed and clinical records we looked at showed these were being acted on.
  • Medicines that required additional monitoring were effectively managed. We saw that patients had the appropriate blood tests prior to prescribing.
  • Vaccination fridges were securely locked and inaccessible to patients.
  • Sharps bins were stored safely.
  • There was evidence of daily cleaning of non-single use items.
  • The practice had completed a patient survey and had developed a transformation plan to increase patient access and satisfaction.
  • The practice had increased clinical capacity and implemented a new telephone system that could enable them to monitor telephone queue length and waiting times.
  • The practice had completed a formal business continuity plan and staff succession plan.

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

10 July 2019

During a routine inspection

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

20 Feb 2019

During a routine inspection

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

8 September and 11 October 2016

During a routine inspection

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