Stopsley Village Practice

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence of an inclusive and positive culture of continuous learning and improvement.

At our last inspection we rated this key question Good.

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

This is because the service was not always led in a way that supported the delivery of high quality care, learning and innovation. Processes for managing risks, issues, and performance were not always effective.

The service was in breach of legal regulation in relation to good governance of the service. We have told the provider they must take actions to establish effective systems and processes and operate them effectively to ensure the service provided a consistently safe and effective service.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us there were good relationships between staff members. They described other staff as friendly, respectful, supportive, welcoming and approachable. A variety of staff told us they felt staff worked well together as a team.

Staff shared a common aim to do the best they could for patients.

The provider shared with us their vision and plans for the future of the practice.

82% of the members of staff who provided feedback for this inspection told us they had not been involved in the planning or development of the vision and plans for the future of the practice.

However, staff were positive about the leadership of the practice. Staff said they felt they were valued members of the team and that leaders welcomed and considered their feedback and ideas. Several staff gave examples of changes that had been made in response to staff feedback.

Staff told us leaders were visible, approachable, supportive and compassionate.

There were arrangements in place to promote staffs’ well-being, including:

• access to an Employee Assistance Programme

• celebrations of birthdays and other major events

• staff gatherings

• individual risk assessments, for example for staff who used computer screens regularly or who were pregnant.

Although leaders understood some challenges affecting the service, leaders did not demonstrate effective strategic leadership of the practice nor awareness of the risks and challenges of the day-to-day running of the practice.. This lack of knowledge meant leaders had not put in place processes for making sure areas needing improvement were identified and acted on and any risks managed. For example:

• Leaders did not acknowledge audits and risk assessments, such as those relating to infection prevention and control, had not always been completed effectively, by people who had the skills and knowledge needed. This meant opportunities to identify risks and act on areas for improvement were missed.

• Although the provider had reviewed the practice’s policies and procedures, mostly in January 2024, they had not identified when the information in them was inaccurate or required updating. This meant the provider had not taken steps to make sure the information in them available for staff to use was accurate and up-to-date. For example, in the practice’s safeguarding policies, fire risk assessment and documents about emergency medicines and equipment.

• Although staff told us they had protected time for learning and development and had completed training in a variety of topics, leaders were not clear and there was no clear training programme about what training the practice required staff to complete. Leaders did not know what training staff had completed or needed to complete.

• Leaders did not show they monitored the competency and performance of all staff and had responded to concerning feedback they had received from external organisations to minimise risks and support staff development.

All staff who provided feedback for this inspection told us they felt comfortable in raising a concern and were not fearful of retribution.

The practice had a Whistleblowing Policy, which had been reviewed in January 2024. This included details about the procedure staff should use to raise a concern and some limited information about organisations staff could contact outside of Stopsley Village Practice if they felt they needed.

The provider also gave us a copy of a Freedom to Speak Up Policy. However, this policy had been produced by a different NHS organisation and did not specifically relate to Stopsley Village Practice.

Although all staff who provided feedback for this inspection told us they knew who the practice’s Freedom to Speak Up Guardian was, and how to contact them, it was unclear if the Freedom to Speak Up Guardian, whose details were provided in the Freedom to Speak Up Policy, was accessible for practice staff.

Freedom to Speak Up Guardians offer support to staff to raise concerns, or speak up, when they feel they cannot in other ways.

Staff told us they felt they treated each other fairly, and that others treated them with equity and inclusion, including those with protected characteristics under the Equality Act.

Staff felt supported and told us others would make time to listen to and help them when needed.

Staff told us they were happy working at Stopsley Village Practice.

A mixture of male and female clinical staff worked at the practice and staff members were from a variety of different nationalities and backgrounds.

We saw there was equity and inclusion across the workforce and no signs staff with particular protected characteristics faced discrimination.

Staff knew where to find policies and guidance and told us they knew who they could speak to if they had a question or concern.

However, we found the actions staff said they would take were not always the same as the processes outlined in practice policies and procedures, such as in the practice’s Business Continuity Plan, dated January 2024. This plan outlined what staff should consider and what actions to take if there was a major incident or disruption to the service, such as a loss of computer or telephone systems, utilities such as gas, electricity and water, flooding, a pandemic, staff incapacity or terrorist attack.

While the plan included the details needed to contact various other services, details in the plan did not match what we found during our site visit to the practice, for example the provision of a staff contact list and the location of emergency medicines and equipment.

The provider did not have effective governance and assurance systems in place, which were regularly reviewed. For example those to provide assurance:

• patients received safe and effective care that was in line with up-to-date national guidance

• systems worked reliably, such as those for monitoring fridge temperatures

• all recruitment checks were completed for all new staff and risk assessments put in place when needed

• staff kept up-to-date with required training

• staff maintained their immunity against infectious diseases as appropriate

• any changes made, for example in response to a safety incident or complaint, were effective and further changes made and reviewed when necessary.

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

Leaders told us they worked with the other GP practices in the PCN, for example in health promotion events.

They told us they worked with their Integrated Care Board (ICB), for example discussing possible ways to create more space for the practice to operate from. ICBs are responsible for planning and delivering local NHS health and care services and work to make improvements and provide better care for people who use services.

Leaders also told us they worked with other community services, such as the Luton Irish Forum and local religious centres.

The practice had an active Patient Participation Group (PPG). We spoke with representatives from the PPG who were positive about the working partnerships between the group and the practice. They told us about how they met regularly with leaders and were involved in service improvements.

For example, at the time of this inspection the practice was about to make changes to how appointments were booked, to using a system called Total Triage. Leaders and members of the PPG told us how they were working together to help make sure the introduction of the system was successful. For example, through trial and education sessions with staff and feedback to leaders about when to launch the new system.

More information about the PPG, a registration form for joining the group, and minutes of past PPG meetings were available on the practice website.

Although there was no embedded quality improvement programme, leaders told us about work they had done to identify more people who had high blood sugar levels but who did not have diabetes, and to test more people for HIV, to help improve their health outcomes.

The practice did not have a strong focus on continuous learning, innovation and improvement.

The practice shared with us audits that had been carried out. Two of the audits had been completed in 2022 and indicated areas for improvement. Although the clinicians who had carried out the audits still worked at the practice, the provider did not share with us evidence of changes made in response to the audit findings or that they had repeated the audit to monitor the practice’s performance.

The other audits carried out by the practice in 2023 and 2024 were in response to concerns shared with the practice by CQC, in line with some of the clinical searches routinely run by CQC in assessments, or completed as part of the ICB’s Prescribing Incentive Scheme (PIS).

For example, the practice had carried out an audit of prescriptions for ‘rescue packs’ for patients with Chronic Obstructive Pulmonary Disease (COPD) for the 2023-2024 PIS. The findings from this audit were similar to our findings from the clinical search we ran for this inspection about prescribing similar rescue packs for patients with asthma.

The practice had become part of a different PCN in April 2023, and was still building relationships and systems with the PCN pharmacy team to help monitor and improve the practice’s performance in monitoring and improving outcomes for patients with long-term conditions or who were prescribed certain medicines.