20 October 2021
Town Centre Surgery provides a range of primary medical services and urgent care treatment to the residents of Luton at:
14-16 Chapel Street,
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.
The registered provider is Herts Urgent Care Limited, also known as HUC, a company that provides services on behalf of the NHS.
The practice is situated within the Bedfordshire, Luton and Milton Keynes (BLMK) Clinical Commissioning Group (CCG) and delivers Alternative Provider Medical Services (APMS) to a patient population of about 11,940. This is part of a locally agreed contract with NHS England and GP Practices.
The practice is a member of a primary care network (PCN) that enables them to work with other practices in the area to deliver care.
Information published by Public Health England shows that deprivation within the practice population group is in the third lowest decile (three of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is, 54% White, 27% Asian, 12% Black, 4% Mixed, and 3% Other.
The practice has a higher that average number of patients aged under 40 years and a below average number aged over 45 years.
The clinical team consists of three GPs, two male and one female and a clinical pharmacist, female. One of the GPs is the clinical lead for the practice. The practice has a team of one practice nurse, one advanced nurse practitioner, one urgent care practitioner and two healthcare assistants, all female. There is a current vacancy for a lead practice nurse. There is a team of reception/administration staff who are led by the practice manager and deputy practice manager.
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 are telephone consultations. If the GP needs to see a patient face-to-face this is then offered to the patient.
The practice is open from 8am to 8pm Monday to Friday and the Urgent Treatment Centre is open from 8am to 8pm Monday to Sunday.
When the practice is closed out of hours services can be accessed via the NHS 111 service.
20 October 2021
We carried out an announced inspection at Town Centre Surgery on 13 September 2021. Overall, the practice is rated as good
Safe - Good
Effective – Requires improvement
Caring - Good
Responsive - Good
Well-led - Good
Following our previous inspection on 9 January 2020, the practice was rated requires improvement overall and for the safe and effective key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Town Centre Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focused inspection to follow up on:
- The key questions inspected: are services safe, effective and well-led.
- Any breaches of regulations and areas where the provider should make improvements identified in the previous inspection.
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.
- Conducting staff interviews using video conferencing and telephone calls.
- 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.
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 and for the population groups older people, people whose circumstances make them vulnerable and people experiencing poor mental health (including people with dementia). The population groups people with long-term conditions, families, children and young people and working age people (including those recently retired and students) have all been rated as requires improvement.
We rated the practice as good for providing safe services because:
Improvements had been made to the systems, practices and processes in place to keep people safe. For example,
- Actions had been taken to ensure staff vaccinations were maintained in line with current Public Health England guidance.
- Blank prescriptions were tracked throughout the practice.
- Risk assessments in relation to health and safety and security had been completed.
We rated the practice as requires improvement for providing effective services because:
- Measures had been taken to improve the monitoring of patients with long-term conditions. However, it was too soon to assess the impact this had for patients.
- Although improvements had been made to the uptake of childhood immunisations the practice remained below the minimum uptake target of 90% and the World Health Organisation (WHO) target of 95%.
- The uptake for cervical screening remained below the Public Health England target of 80%.
We rated the practice as good for providing well-led services because:
- Governance structures were in place to support the management of the practice.
- Actions were taken to support the maintenance of the service during the COVID-19 pandemic.
- Staff reported they felt supported by the GPs and practice management.
- Improvements had been made to support carers registered with the practice.
Whilst we found no breaches of regulations, the provider should:
- Continue to take action to increase the uptake of cervical screening and childhood immunisations.
- Complete reviews in line with local and national guidance for patients with long-term conditions.
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