The Care Quality Commission
  • Doctor
  • GP practice

Archived: Kingsway Health Centre

Overall: Good read more about inspection ratings

385 Dunstable Road, Luton, Bedfordshire, LU4 8BY (01582) 847808

Provided and run by:
Phoenix Primary Care Limited

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

All Inspections

20 August 2019

During a routine inspection

We undertook a comprehensive inspection of Kingsway Health Centre on 4 July 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The practice was rated as requires improvement. The full comprehensive report on the July 2018 inspection can be found by selecting the ‘all reports’ link for Kingsway Health Centre on our website at www.cqc.org.uk

This inspection was an announced comprehensive inspection carried out on 20 August 2019 to confirm that the practice had carried out the required improvements that we identified during our previous inspection on 4 July 2018. Overall the practice is now rated as good.

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 with requirements improvement for responsive and all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Staff were trained to appropriate levels to safeguard children and adults.
  • The overarching governance structures from the provider organisation were embedded in the practice.
  • Learning was identified and shared from significant events and complaints.
  • Patients received effective care and treatment that met their needs.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The provider had taken many actions to meet the expectations of their patients and attempt to improve patient satisfaction. However, patient satisfaction remained lower than other practices both locally and nationally in some areas.
  • Patient engagement events were held to provide the opportunity for patients to meet with practice staff and express their views.

Whilst we found no breaches of regulations, the provider should:

  • Improve the identification of carers to enable this group of patients to access the care and support they need.
  • Continue to encourage patients to participate in cancer screening programmes.
  • Continue to monitor patient feedback and take appropriate actions to improve patient satisfaction.

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

04/07/2018

During a routine inspection

This practice is rated as Requires Improvement overall. (Previous rating; inspected July 2017, published September 2017 – Requires Improvement)

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Good

We undertook a comprehensive inspection of Kingsway Health Centre on 20 July 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The practice was rated as requires improvement for providing caring and responsive services. The full comprehensive report on the July 2017 inspection can be found by selecting the ‘all reports’ link for Kingsway Health Centre on our website at .

This inspection was an announced comprehensive inspection carried out on 4 July 2018 to confirm that the practice had carried out the required improvements that we identified during our previous inspection on 20 July 2017. Overall the practice is now rated as good.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Data from the national GP patient survey, published July 2017, showed patients rated the practice lower than others for all aspects of care and with how they could access care and treatment. We saw evidence of the practice’s ongoing efforts to improve patient satisfaction, including investment in new technologies to improve access. Comments cards received from patients reflected on improvements within the service over time.
  • All patients we spoke with had been able to access care when they needed it.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • 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.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

  • Continue to review and consolidate staff immunity records to ensure that the practice is operating in accordance with Public Health England guidance.
  • Continue to monitor the management of pathology results to ensure that all results are reviewed by a clinician in a timely manner.
  • Ensure that staff are provided with clear guidance and training when assigned new roles and that review is undertaken routinely to ensure newly assigned responsibilities are being fulfilled.
  • Continue monitoring patient satisfaction and efforts to improve patient satisfaction with the service.
  • Continue with efforts to identify and support carers.
  • Continue to engage with eligible patients to improve uptake of cervical and bowel screening.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

20 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kingsway Health Centre on 12 July 2016. The overall rating for the practice was requires improvement with inadequate for providing caring services. The full comprehensive report on the 12 July 2016 inspection can be found by selecting the ‘all reports’ link for Kingsway Health Centre on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection on 20 July 2017. The practice had made considerable progress whilst some areas required further improvement, overall, the practice remains rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • 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 practice had a clear strategy and supporting business plans which reflected the vision and values and were regularly monitored. The business development plan included areas of focus, for example, staff development, enhanced services and improving patient experience.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
  • Data from the Quality and Outcomes Framework showed patient outcomes were mixed with some areas below the local and national averages. However, the practice had taken steps to address these areas and unpublished data showed improvements had been made.
  • Data from the national GP patient survey, published July 2017, showed patients rated the practice lower than others for all aspects of care and with how they could access care and treatment.
  • Patients told us they were not always involved in decision making about the care and treatment they received and sometimes felt rushed during consultations.

The areas where the provider should make improvements are:

  • Implement and review outcomes of the practice improvement plans to increase patient satisfaction with the service.
  • Monitor patient feedback through the national GP patient survey and practice surveys to continue to identify and ensure improvement to patient experience.
  • Continue to identify and support carers.
  • Continue to encourage patients to attend cancer screening programmes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

12 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kingsway Health Centre on 12 July 2016. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety, however systems in place for reporting and recording significant event outcomes and action need strengthening.
  • Risks to patients were assessed and well managed, however, the system for recording and cascading information from MHRA alerts was inconsistent.
  • Some staff files held incomplete records and recruitment checks undertaken for some staff could not be established.
  • 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.
  • The practice had a corporate vision to deliver high quality care, promote good outcomes for patients and to be caring, show compassion and understanding.
  • Patient feedback was mixed. Some patients told us they were satisfied with the care they received and thought staff were respectful and caring. Whilst others told us that access was difficult and some staff were rude or appeared disinterested.
  • Data from the national GP patient survey showed patients rated the practice lower than others for most aspects of care.
  • Patients said they found it difficult to access the practice by telephone and to make an appointment with a named GP.
  • Systems for seeking and responding to patient feedback were not effective. Notably, the practice did not have an active patient participation group.
  • 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.
  • The practice had facilities suitable for people with disabilities and patients with young children, including access enabled toilets and baby changing facilities.
  • There was a leadership structure and staff said they felt supported by management. The practice sought feedback from staff and patients, which it acted on.
  • The practice development plan did not reflect local priorities.

The areas where the provider must make improvement are:

  • Implement a process to ensure that incidents and significant events and safety alerts are recorded appropriately, including dissemination and sharing of learning to all relevant staff
  • Ensure feedback is routinely obtained and considered from patients using the service.

The areas where the provider should make improvement are:

  • Ensure a programme of regular staff appraisals to support staff development
  • Review arrangements for uncollected prescriptions.
  • Continue to identify and support carers.
  • Implement a comprehensive system for quality improvement, including, for example, a programme of clinical audits.
  • Continue to encourage patients to attend cancer screening programmes.
  • Ensure all staff are aware of their role regarding the duty of candour requirements.
  • Continue to develop business and strategic plans to reflect local and practice needs.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice