• Doctor
  • GP practice

Carlton Group Practice

Overall: Good read more about inspection ratings

Carlton Street, Burton On Trent, Staffordshire, DE13 0TE (01283) 511387

Provided and run by:
Carlton Group Practice

Latest inspection summary

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Background to this inspection

Updated 24 September 2021

Carlton Group Practice is in Burton on Trent at:

Carlton Street
Horninglow
Burton on Trent
Staffordshire
DE13 0TE

The practice has a branch surgery at:

King Street
Burton on Trent
Staffordshire DE14 3AG

We visited the King Street site as part of this inspection activity.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures. These are delivered from both sites apart from surgical procedures, which are not performed at the King Street site.

The practice offers services from both a main practice and a branch surgery. Patients can access services at either surgery.

The practice is situated within the East Staffordshire Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 16008. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices the East Staffordshire Primary Care Network.

The Carlton Street Surgery is a converted church built in circa 1900 and the building is owned equally by all the current Partners.

Carlton Street Surgery consists of one treatment room, one surgical (minor operations) room and 11 consulting rooms. Previous administrative rooms on the first floor were converted to consulting rooms in 2018 giving the Practice a further three consultation rooms. These are accessed via a staircase and a stair lift for less abled patients, however the practice try to arrange to see these patients in a room on the ground floor.

There is limited parking on site but ample free street parking locally. Carlton Street Surgery opens from 8.00am to 6.00pm Monday to Friday and operates extended access and extended hours clinics.

King Street Surgery is a leased building with one treatment room and four consultation rooms. There is a car park on site. King Street Surgery operates from 8.00am – 1.00pm Monday to Friday. King Street Surgery is sited in a dated building with acquired historic issues affecting infection control and health and safety. The practice has worked closely with the CCG to identify ways to improve the conditions at King Street Surgery. The practice was awarded two improvement grants which enabled them to make significant improvements to both the clinical and administrative areas within the surgery.

Due to the age and size of both buildings it is proposed that Carlton Group Practice will relocate to the Outwood’s Health Village opposite the site of Queens Hospital Burton as part of a project planned for completion in 2024. The engagement process is in place and all patients over the age of 16 have received a letter from the practice informing them of the proposed move and inviting the patients to share their views via a survey; this can either be completed online or a paper copy can be sent to the patient at their request. The letter can also be accessed in alternative languages at the patients request. The PPG and internal staff group have been made aware and involved in the discussions regarding the proposed move.

Information published by Public Health England shows that deprivation within the practice population group is in the fourth lowest decile (four of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 84.5% white, 11% Asian and 2.2% mixed race.

The practice area has a higher level of deprivation being in the fourth most deprived decile but has two wards which are amongst the 12 most deprived areas nationally. The Income Deprivation Affecting Children (IDAC) indicators (21%) were higher than the CCG (14%) and England (20%) averages which demonstrates higher levels of deprivation. This may mean that there is an increased demand on the services provided when compared with national averages. The practice population distribution is broadly in line with local and national averages.

There is a team of five GP partners, two salaried GPs and one retainer GP who provide cover at both practices. The practice has two clinical pharmacists, a lead nurse and four practice nurses supported by two healthcare assistants and a phlebotomist. The clinical team are supported by a business manager, an operations manager and a finance and management administrative assistant. There is one reception manager and a team of 11 receptionists. There are two care coordinators, a data quality officer, a medical records administrator, an additional clinics administrator and a medical secretary.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery. The branch surgery served as the red practice during the locked down periods of the covid-19 Pandemic as they could ensure one patient into the premises and one patient out to promote everyone’s safety.

Extended access is provided locally by the Primary Care Network and the practice participate on a rota basis.

Additionally, an online digital service is available on Sunday mornings where appointments are offered with a GP via the Q Doctor App. All practices across East Staffordshire are participating in this extended access. Further information can be found at; www.eaststaffsccg.nhs.uk/your-health/ extended-primary-care-services

Out of hours services are provided by Vocare.

Overall inspection

Good

Updated 24 September 2021

We carried out an announced inspection at Carlton Group Practice on 17 August 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 11 February 2019, the practice was rated Requires Improvement overall and for key questions safe, caring and well-led.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Carlton Group Practice on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive review of information with a site visit inspection to follow up on a breach of Regulation 17 Health and Social Care Act 2208 (Regulated Activities) Regulations 2014, Good governance.

This was because:

There were gaps in the practice governance systems and processes to ensure compliance with requirements to demonstrate good governance.

In particular:

  • There was a lack of a systematic approach for oversight of records of skills, qualifications and training for all staff.
  • There was no system in place to follow up children's non-attendance at secondary care appointments.
  • The safeguarding policies did not reflect updated categories of abuse.
  • The practice lacked a clear audit trail for patient safety and medicine alerts patient searches. The arrangements for identifying, recording and managing risks, issues and implementing mitigating actions were not operated effectively.
  • Infection Prevention and Control processes had not been adequately applied at the King Street site.
  • The practice did not have risk assessments in place in relation to medicines for use in the event of an emergency not held at the practice sites.
  • The practice had not ensured that both practice premises had appropriate documented health and safety and security risk assessments in place. However, an external company was employed to undertake these assessments on 15 February 2019.

At the inspection in August 2021 we found that the provider had satisfied the requirements of the regulation.

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
  • 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
  • A telephone conference call with the Patient Participation Group
  • Telephone calls with care and nursing home who received a GP service from the practice.

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 good for all population groups except Working age people (including those recently retired and students) families, children and young people and people with long term conditions, which we rated as Requires Improvement.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • Not all patients received effective care and treatment that met their needs.
  • Clinical data for patients with long term conditions, families, children and young people and working age people was negative in some areas. The practice was aware of this and had developed recovery plans to review and manage these areas.

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

  • Continue to develop the significant event process and root cause analysis.
  • Review and improve how carers are identified and recorded.
  • Continue to review the backlog for monitoring of patients who have long term conditions.
  • Improve engagement with those eligible for cervical cytology and cancer screening.
  • Continue to improve the uptake of childhood immunisations.

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