The Care Quality Commission
  • Doctor
  • GP practice

Town Centre Surgery

Overall: Good read more about inspection ratings

14-16 Chapel Street, Luton, Bedfordshire, LU1 2SE (01582) 709290

Provided and run by:
Herts Urgent Care Limited

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Town Centre Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Town Centre Surgery, you can give feedback on this service.

13 September 2021

During an inspection looking at part of the service

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.

This included:

  • 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.

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 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

9 January 2020

During a routine inspection

We carried out an announced comprehensive inspection at Town Centre Surgery on 9 January 2020. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, as part of our inspection programme.

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 requires improvement for the People with long-term conditions, Families, children and young people and Working age people (including those recently retired and students) population groups. The Older people, People whose circumstances may make them vulnerable and People experiencing poor mental health (including people with dementia) population groups are rated as good.

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

  • Staff vaccination records were not maintained for all staff.
  • Blank prescriptions were not tracked throughout the practice.
  • Risk assessments in relation to premises/security and health and safety had not been formally completed.

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

  • The practice scored lower than others for quality and outcomes framework (QOF) indicators relating to patients with long-term conditions.
  • The uptake for cervical screening was below the Public Health England target of 80%
  • The uptake for baby immunisations was below the World Health Organisation target of 90%.

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

  • Staff dealt with patients with kindness and respect.
  • Feedback from patients was positive regarding the care they received.
  • The practice had identified 14 patients as carers which equated to 0.1% of the practice population. Carers were supported with flexible appointment booking health checks and flu vaccinations.

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

  • Actions had been taken in response to patient feedback to improve services since the provider had taken over the practice.
  • A wide range of appointments were available including in the evenings.

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

  • The leadership within the practice was supported by the provider support centre which provided clinical and operational leadership and support, training and development.
  • Staff reported that they felt supported by the GPs and managers in the practice.
  • The practice had not been able to establish a patient participation group. However, they proactively sought the views of patients via the NHS Friends and Family Test.

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Continue to take actions to increase the uptake of cervical screening and baby immunisations.
  • Complete reviews in line with local and national guidance for patients with long-term conditions.
  • Improve the identification of carers to enable this group of patients to access the care and support they need.
  • Continue to monitor patient feedback and take appropriate actions.

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