Stopsley Village Practice

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence people had the best possible outcomes because their needs were assessed and care and treatment was provided in line with up-to-date best practice.

At our last inspection we rated this key question Good.

At this inspection, the rating has changed to Requires Improvement.

This is because patients’ needs were not always assessed, and care and treatment were not always delivered in line with current legislation, standards and evidence-based guidance.

This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

About 13% of patients registered with the practice had 1 or more long-term conditions, such as asthma, chronic kidney disease (CKD), diabetes or hypothyroidism.

Most patients with long-term conditions had the appropriate monitoring and reviews, in line with national guidance, to check their health and medicines needs were being met.

Our searches of the practice’s clinical records system included patients with asthma who had been prescribed 2 or more ‘rescue packs’ in the last year and patients with hypothyroidism who had not been monitored in line with national guidance.

We found 43 patients with asthma who had been prescribed 2 or more ‘rescue packs’ in the last year. These packs contain medicines used to treat flare ups of asthma. Repeated use of these medicines can indicate the patient’s asthma could be better controlled. We looked at the patient records for 5 of these patients. We found patients had not always been adequately assessed before rescue packs were prescribed, some rescue packs had been issued on repeat prescriptions, and patients were not always followed-up after a flare-up of their asthma to make sure their immediate and ongoing needs were fully addressed. The practice told us most of these patients are under the care of hospital specialists, who had advised the practice to prescribe rescue packs if the patient had a flare-up of their asthma. However, this could be made clearer in the patients’ records, including an explanation for issuing the medicines using repeat prescriptions when this was appropriate. The provider told us they would make sure patients are followed-up after a flare-up of their asthma. However, they did not tell us how they would do this.

We found 7 (2%) of the 337 patients who had hypothyroidism had not been monitored in line with national guidance. We looked at the patient records for 5 of these 7 patients. The practice was aware the monitoring was overdue for 4 of the 5 patients. Although the practice had recorded medicine reviews in the year leading up to this inspection for 3 of the patients, the monitoring was significantly overdue for all 4 patients and for 2 of the patients their last test results were not in the expected range. This meant we did not know if these patients’ long-term condition was managed as well as possible and the dose of medicine prescribed for them was safe and effective. Following our feedback, the practice arranged for the monitoring to be completed for 2 patients and stopped prescribing the medicine for hypothyroidism for another patient. The practice told us the fourth patient had been monitored, but that their systems for checking and documenting when staff had reviewed test results held on hospital computer systems could be strengthened. The practice told us they planned to set up a system to keep track of patients needing monitoring and to run a yearly audit to identify any patients overdue monitoring for hypothyroidism.

Patients presenting with symptoms which could indicate serious illness were not always followed up in a timely and appropriate way. We found the systems to identify these patients and make sure they were offered the appropriate investigations, treatment and monitoring were ineffective.

Our searches of the practice’s clinical records system identified 236 patients whose test results suggested they may have more severe chronic kidney disease but for whom the diagnosis had not been recorded on the patient’s record. We looked at the records for 5 of these patients and found no evidence any of the patients had been informed about the diagnosis. However, 4 of the patients had had appropriate follow-up investigations, and 2 of the patients were prescribed suitable medicine(s) to help protect them from further kidney damage. There was no evidence the practice had responded to the test results for 3 of the patients for at least 8 months.

In response to our feedback, the practice told us they had already started to review these patients and had found 50% of the 236 patients we identified were already prescribed appropriate medicines and having the necessary monitoring. The practice told us they would update the records for the remaining patients and set up a system to identify patients who may have a missed diagnosis.

The GP Patient Survey is an independent national survey that tells us how people feel about their GP practice.

90% of the people who responded to the 2024 GP Patient Survey said during their last appointment they were involved as much as they wanted to be in decisions about their care and treatment. This was in line with local and national averages.

However, the practice performed slightly below national and local averages in questions about people’s experiences of the practice. Of the people who responded to the survey:

• 65% responded positively to the overall experience of their GP practice (compared with 74% nationally and 66% in the Bedfordshire, Luton and Milton Keynes (BLMK) area).

• 81% said during their last appointment the healthcare professional was very good or fairly good at listening to them (compared with 87% nationally and 83% in the BLMK area).

• 77% said during their last appointment the healthcare professional was very good or fairly good at treating them with care and concern (compared with 86% nationally and 81% in the BLMK area).

• 87% said during their last appointment they had confidence and trust in the healthcare professional they saw or spoke to (compared with 92% nationally and 89% in the BLMK area).

Although direct comparisons cannot be made with the findings from previous years’ GP Patient Surveys because the way information was collected changed, the findings from the 2024 survey could indicate improvements since the 2023 survey.

7 reviews about the practice had been posted on the NHS website in the year leading up to this inspection. The people leaving 6 of these reviews rated the practice either 4 or 5 stars, out of 5, meaning they would be likely or extremely likely to recommend the service to friends and family.

Comments posted in these online reviews and most people who provided feedback for this inspection described staff as helpful, patient, understanding, kind, respectful, friendly and polite.

However, we also received some negative feedback and the remaining online review was negative about the approach of some clinicians. We also received feedback that clinical and non-clinical staff were more approachable and helpful now than had been the case previously.

Leaders told us staff attended practice clinical meetings where clinical guidelines and updates were shared and discussed.

However, clinicians told us they did not always attend the meetings because they were held on days when they did not work at the practice or did not have time to attend them. These staff told us they read the minutes of the meetings and emails for information.

We looked at the minutes of clinical meetings, which had been held monthly between March and September 2024, and found:

• No evidence some clinical staff, including physician associates, advanced nurse practitioners, practice nurses and members of the pharmacy team, had attended the meetings. Of the 21 clinical staff who worked at the practice at the time of this inspection, the minutes of the meetings indicated only the two GP partners had attended more than 2 of the meetings.

• While 7 different clinical guidelines had been discussed, no recent updates had been made to at least 4 of them and we did not see information about new or updated guidelines was always shared with staff.

Clinical staff told us they kept up-to-date by looking at information online, such as about MHRA alerts and guidelines from the National Institute for Health and Care Excellence (NICE), local guidance about prescribing medicines, completing online training, reviewing literature, and discussions with other clinicians in the practice and with others from the same profession working at other practices.

Although clinicians told us they discussed patients they had seen with one of the doctors at the end of each day, the provider did not show us they had effective systems in place for keeping staff up-to-date with national guidelines, legislation and evidence-based good practice.

There were not effective processes in place to show staff worked according to these.

Our searches of the practice’s clinical records system indicated not all patients received care that was in line with national guidance.

However, information from the NHS Business Services Authority showed the practice’s prescribing of antibiotic, hypnotic and ‘Z drug’ medicines and of multiple psychotropic medicines was acceptable.

We did not receive specific examples from patients about how staff, teams and services worked together. However, we did receive positive feedback about the efficiency with which the practice shared a patient’s clinical records with another GP practice when the patient was studying at university away from their home.

Staff told us they were proud of how practice staff worked well together as a team to meet the needs of their patients.

Partners, for example the care home to which Stopsley Village Practice is aligned, told us they felt they worked with the practice well and as a team.

They told us the practice responded to queries they raised by telephone or email and that responses to medicines management issues were well coordinated by the practice’s doctors and pharmacists and were resolved quickly.

The practice and care home discussed all residents in a monthly online meeting.

There were systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.

Practice staff attended monthly meetings with other teams and services to discuss and coordinate care for patients who have more complex needs.

There were appropriate referral pathways to make sure that patients’ needs were addressed.

The practice supported national priorities and initiatives, for example by providing information for people aiming to stop smoking or manage their weight, and by running a flu jab service on a Saturday in October 2024.

People told us they felt the practice informed patients well about this campaign and that getting their seasonal vaccinations, such as flu jabs, was “hassle-free”.

A high number of people attending this flu jab service also took up an offer of a check of their blood pressure and weight before leaving the clinic.

Support from Health and Wellbeing Coaches and a Social Prescriber was available for patients registered with Stopsley Village Practice.

Social prescribers work with other professionals to connect people to a variety of services to meet their social, emotional and practical needs. Social prescribers can support a patient or carer to access the right services to help with issues which are affecting their health and wellbeing, for example those living with low mood or a long-term health condition, feeling lonely or isolated, or struggling with personal situations such as worries about money.

Information was available on the practice’s website, including about local community groups, services and support groups, for example about autism, mental health, elderly care, drug and alcohol problems, sexual health, child health and specific long-term conditions such as multiple sclerosis.

Information for those affected by bereavement was available on the practice’s website and in the waiting area in the practice. This included information about specialist support services such as for those affected by stillbirth, palliative care and deaths or serious injuries from road collisions.

The practice identified people who may need extra support, for example unpaid or family carers. An unpaid or family carer is anyone who looks after a family member, partner or friend who needs help because of their illness, frailty, disability, mental health needs or drug or alcohol problem and cannot cope without their support. The care they give is unpaid.

At the time of this inspection, the practice had 238 unpaid or family carers on their register. This was about 2.5% of the patients registered with the practice.

Information for carers was available on the practice’s website and in the waiting area in the practice. This included information specifically for young carers, meaning those under the age of 18.

We did not receive specific feedback from people about their experiences.

The practice offered patients with a learning disability a yearly health check. The practice told us they had completed a health check for all patients who had been registered with the practice for a year or longer and for whom a learning disability had been recorded.

Patients aged 75 and over are eligible for a NHS health check. The practice had recorded a health check for only 3 of the 860 eligible patients registered with the practice. However, the practice had completed various aspects of the health check for some other patients. The practice told us they were planning to look at these patients’ records and make sure a health check was recorded for them.

Patients aged between 40 and 74 are also eligible for a NHS health check. The practice told us they had completed a health check with 443 of the 1610 (28%) eligible patients registered with the practice.

The latest information from the UK Health Security Agency (UKHSA) showed the practice had not met national targets for the number of children immunised against various infectious diseases. The national target is 95%. Data from the UKHSA showed:

• 90% of children aged 1 had completed a course of immunisation for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus influenza type b (Hib) and Hepatitis B (Hep B).

• 71% of children aged 2 had received a booster immunisation for Pneumococcal infection (PCV booster).

• 72% of children aged 2 had received a booster immunisation for Haemophilus influenza type b (Hib) and Meningitis C (MenC).

• 68% of children aged 2 had had their first dose of immunisation for measles, mumps and rubella (MMR).

• 75% of children aged 5 had had 2 doses of immunisation for MMR.

Although the numbers of children aged 1 being immunised had been increasing since March 2021, the general pattern for the other indicators above was fewer children having immunisations.

The practice monitored the numbers of children having the recommended childhood immunisations.

The practice supported a population of Irish Travellers and had identified the uptake of childhood immunisations was lower in this group of people. Practice leaders told us they worked with a local charity to help raise awareness about the benefits of immunisation and increase confidence in vaccinations.

Cervical screening (a smear test) is one of the best ways to help protect against and prevent cervical cancer. The latest information from NHS Digital showed that on 30 June 2023, 68% of patients registered with the practice who were eligible for this screening had been screened adequately within the recommended time period. This period is 3 years 6 months for people aged between 25 and 49, and of 5 years 6 months for people aged between 50 and 64. The national target is 80%. We saw the coverage of patients being screened had been consistently below this target since 2017.

The practice monitored the uptake of cervical screening. The practice told us, at the time of this inspection, 75% of people aged between 25 and 49, and 81% of people aged between 50 and 64 who were eligible had been screened.

There was a noticeboard in the practice’s waiting area with information and encouraging eligible patients to book an appointment for a smear test.

Practice leaders told us they had attended a variety of events to help raise awareness and reduce health inequalities in the local community. These had included events in local churches and mosques to try to encourage more people to have a smear test.

We did not receive specific feedback from people about their experiences.

Patients were advised chaperones were available and were offered a chaperone when appropriate.

Although the procedure described by staff who acted as chaperones was appropriate, we did not see evidence staff who acted as chaperones had completed training to help make sure they did so safely and following appropriate and up-to-date procedures.

Staff told us they obtained consent from patients or someone with the appropriate authority when appropriate.

However, the practice did not have a clear system in place for verifying and recording any arrangements patients had in place allowing another person to make decisions on their behalf, such as a Power of Attorney.

There was information on the practice’s website about confidentiality and accessing patient health records, including requesting someone else’s information.