Gardiner Crescent Surgery

Updated 6 December 2023

Gardiner Crescent Surgery (also known as The Villages Medical Group) is located in Chester-le-Street and Stanley at:

Gardiner Crescent Surgery,
21 Gardiner Crescent,
Pelton Fell,
Chester-le-Street,
DH2 2NJ

There is a branch surgery at:

Craghead Medical Centre,
The Middles,
Craghead,
Stanley,
DH9 6AN

Care and treatment is provided to patients of all ages, to a patient population of about 4,300 patients. This is part of a contract held with NHS England. The practice is situated in Durham and is within the North East and North Cumbria Integrated Care Board (ICB) area. The practice is part of a wider network of 7 GP practices, in the Primary Care Network for Chester-le-Street.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning, treatment of disease, disorder or injury and surgical procedures.

Information published by Public Health England shows that deprivation within the practice population group is in the 3rd decile (3 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 0.8% Asian, 0.4% black, 98.7% White, 0.4% Mixed and 0.1% other.

There is a GP. The practice has a team of 2 nurses who provide nurse-led clinics for long-term conditions, an advanced nurse practitioner and a health care assistant. The clinical team are supported at the practice by a team of reception and administrative staff.

The practice is open between 8.30am to 6pm Monday to Friday and closed between 12.30pm and 1.30pm. The practice offers a range of appointment types including those available to book on the day, telephone consultations and advance appointments.

Extended access appointments are available as part of primary care network and federation working on an evening, between 6.30pm and 8pm, and on a weekend between 8.30am and 12pm. Out of hours services are provided by calling 111, who would book patients into any available hub or sub hub slots for patients.

Updated 6 December 2023

We carried out an announced comprehensive at Gardiner Crescent Surgery on 27 June and 5 July 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement.
Effective - requires improvement.
Caring – good.
Responsive – requires Improvement.
Well-led – requires Improvement.

Following our previous inspection on 20 September 2022, the practice was rated inadequate overall and for all key questions apart from caring which was rated as requires improvement. The practice was placed into special measures as a result of an earlier inspection in May 2022 and remained as special measures following our inspection in September 2022. We took enforcement action at our previous inspections and this inspection was to check if the provider had made sufficient improvements.

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

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection and check on any improvements made.

We inspected:

• All key questions
• We checked progress with improvement against the following breaches of regulation found during previous inspections including, good governance (regulation 17); staffing (regulation 18); fit and proper persons employed (regulation 19); safe care and treatment (regulation 12); receiving and acting on complaints (regulation 16).

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A short site visit.
• Sending out a questionnaire to staff.

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 found that:

At this inspection in June/July 2023, we found compliance with Regulation 12 safe care and treatment and Regulation 19 Fit and proper persons employed. However, we found continued non-compliance with Regulation 16 Complaints, Regulation 17 Good governance and Regulation 18 Staffing. The practice is therefore rated as requires improvement overall. There was clear evidence of the provider taking action to improve the quality and safety of the service following the last CQC inspection. However, this has been reactive to those issues reported via the CQC inspection process or via commissioners. Improvement is still required.

We rated the practice as requires improvement for providing safe services because:

• There were gaps in systems to assess, monitor and manage risks to patient safety.
• The practice did not have an effective system to learn and make improvements when things went wrong.

We rated the practice as requires improvement for providing effective services because:

• Whilst staff had the skills, knowledge, and experience to carry out their roles and were supported, the systems in place did not support mangers to have oversight of staff training levels for either mandatory or specialist training.
• A programme of targeted quality improvement was not in place.

We rated the practice as good for providing caring services because:

• Staff treated patients with kindness, respect, and compassion.
• Staff helped patients to be involved in decisions about care and treatment.
• The practice respected respect patients’ privacy and dignity.

We rated the practice as requires improvement for providing responsive services because:

• We found that those areas previously regarded as inadequate had improved but there were still some gaps and areas for improvement identified.
• The practice took some steps to organise and deliver services to meet patients’ needs. However, delivery of such services was impacted by reduced clinical staffing levels meaning services did not always meet patients’ needs.
• The provider was now responding to the needs of patients with long term conditions and addressing health inequalities. Translation and interpretation services were available.
• The practice had put in place some measures to address gaps in access, but these measures were not sustainable in the long term.
• The practice had improved complaint handling processes, but this required more time to be fully embedded.

We rated the practice as requires improvement for providing well-led services because:

• Leaders could not demonstrate that in isolation they had the capacity and skills to deliver high quality sustainable care.
• There was no clear strategy in place but there was a commitment to improve and provide high quality care.
• The overall governance and management arrangements were not always effective.
• There were gaps in the systems and processes for managing risks, issues, and performance.
• There was some involvement of the public, staff, and external partners to sustain high quality and sustainable care.
• There was some evidence of systems and processes for learning and continuous improvement. Innovation was not demonstrated.

We found 3 breaches of regulations. The provider must:

• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.

The provider should:

• Implement the remaining actions from the infection prevention and control audit.
• Reduce the risk of antibacterial resistance by continuing to monitor and reduce the inappropriate prescribing and overuse of antibiotics.
• Improve information about support groups on the practice website.
• Take action to ensure all staff are aware of who the Freedom to Speak Up Guardian is.

This service was placed in special measures in July 2022. Following a further inspection in September 2022 where we found insufficient improvements we took action in line with our enforcement procedures to begin the process of preventing the provider from operating the service.

In this third inspection we found that sufficient improvements have now been made. I am taking this service out of special measures. This recognises the improvements that have been made to the quality of care provided by this service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care