Larksfield Surgery Medical Group in Stotfold has been rated ‘requires improvement’ by the Care Quality Commission after an inspection raised concerns over its responsiveness and safety.

The inspection was carried out in March this year 2024, saw its rating fall from good, in July 2017, to requires improvement.

It was found that the responsiveness of the surgery was inadequate – “not delivering services to meet patient’s needs”.

The report, published on August 27, identified that there were risks relating to “fire, Legionella, infection prevention and control, medical emergencies, the appropriate and safe use of medicines, and for making sure staff had the skills, knowledge, and experience to carry out their roles safely and effectively”.

During the inspection, the CQC discovered that the practice did not prioritise care for the most clinically vulnerable patients, to ensure that the appointments available were given to the patients most appropriate for them. 

In regard to effectiveness, the report highlighted the monitoring of patients with severe chronic kidney disease (CKD), stages four and five. The search identified “33 patients” who were coded as having this diagnosis, with “17 patients” noted as not having had the necessary blood test monitoring in the last nine months. 

The practice did not always identify when a patient’s test results indicated they had an "undiagnosed condition", such as diabetes.

The report identified “26 patients as having a potential missed diagnosis of diabetes”.  

When looking at the records of four of these potential patients, the CQC found that two of them had diabetes, but they had not been “informed or offered advice, medicines, screening and other treatments to help limit any harm”.

560 responses were provided by patients through Give Feedback on Care. The most significant concern was “inability to access” the practice - the two main barriers were a lack of “available appointments” and “booking processes”, leading to long queues and patients finding assistance elsewhere.

Staff also voiced their concerns, suggesting that they felt that “they could speak up but their voice may not be heard” and “compassionate, inclusive, and capable leadership was not evident at all levels”. 

Furthermore, there was evidence that only “16 of the 45 staff” working at the practice had completed the required appropriate training in “basic life support”.

The CQC did identify the care rating as good however, it did not assess this category and based the score on the previous inspection’s result. 

No enforcement action has been taken by the CQC, but further information regarding action may be published on its website soon.

To view the report in full, go to cqc.org.uk/location/1-545132452.

A spokesperson for Bedfordshire, Luton and Milton Keynes Integrated Care Board said: “We are aware that the Care Quality Commission has published its report, following a visit to Larksfield Surgery in Stotfold earlier this year.

“We have been supporting the practice through a change of management which took place following the inspection, and we continue to work with the surgery and its staff as they rapidly address the issues raised by the CQC’s report.”