Gordon Street Surgery

Updated 12 July 2023

Gordon Street Surgery is located in Burton-on-Trent, Staffordshire at:

Gordon Street Surgery

72 Gordon St,

Burton-on-Trent

DE14 2JA

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.

The practice is situated within the Staffordshire and Stoke on Trent Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of 10,630. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices, East Staffordshire.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the third lowest 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 21.1% Asian, 1.5% Black, 2.4% Mixed, 0.6% Other and 74.5% White.

The age distribution of the practice population closely mirrors the local and national averages. There are more male patients registered at the practice compared to females.

There is a team of four GP partners, and two long term-locum GPs. The practice employs an Advanced Nurse Practitioner and Pharmacist. The practice has two practice nurses, a healthcare assistant and a phlebotomist. The GPs are supported at the practice by a practice manager, reception manager, an assistant to reception manager and medical secretary as well as a small team of reception and administration staff.

The practice is open between 8am to 6pm Monday to Friday. Between the hours of 6pm and 8am, patients are advised to call NHS 111. The practice offers a range of appointment types including urgent book on the day, telephone consultations and online pre bookable appointment slots.

All practices across East Staffordshire participate in an enhanced access programme.

Out of hours services are provided by Staffordshire Doctors Urgent Care.

Updated 12 July 2023

We carried out an announced comprehensive inspection at Gordon Street Surgery. Remote clinical searches took place on 10 May 2023 with an onsite inspection on 15 May 2023.

Overall, the practice is rated as inadequate.

Safe - requires improvement.

Effective - requires improvement.

Caring – requires improvement.

Responsive - inadequate

Well-led - inadequate

Our last announced review took place on 22 September 2021 to review the warning notice served to Gordon Street Surgery for breaches under Section 29 of the Health and Social Care Act 2008. We served the warning notice on 1 July 2021 and had required the practice to be compliant with Regulation 19(1) and 19 (2) Fit and Proper Persons employed, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, by 8 September 2021. We reviewed the breach within Schedule Three of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 “all potential and employed staff.” However, we did not review other breaches or re-rate the practice at the 22 September review. Therefore, the ratings from the previous inspection in June 2021 remained unchanged: these ratings were requires improvement overall and inadequate for providing a safe service.

At the inspection on 15 May 2023, we found that some improvements had been made in the areas identified at the previous inspection in providing a safe service, for example:

• The review and management of the cleaning and routine maintenance of the practice.
• Formalised supervision arrangements for non-medical prescribers and nursing staff.
• Recruitment checks to ensure staff had the appropriate qualifications skills and experience necessary for the work they performed and physical/mental health checks to ensure staff were able to carry out their role.
• Improvements were identified in the significant event reporting and root cause analysis process.

However, gaps remained, for example:

• Recruitment records were missing references for two staff including checks of conduct in previous employment and a disclosure and barring check was not completed to the level appropriate to the role.
• Not all staff had achieved safeguarding training at the appropriate level for their role.
• Significant event trend analysis and sharing learning from these events with the whole team had yet to take place, although it was planned.
• Nominated staff had not completed fire marshall training, however at the time of the onsite inspection visit, on 15 May 2023, this had been completed.
• Not all staff had completed dementia awareness training.
• There was no clear route for inclusion of clinical staff in policies which had a clinical element.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Gordon Street 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 to follow up concerns reported to us.

The focus of this inspection included:

• Safe, Effective, Caring, Responsive and Well led domains.
• We followed up breaches of regulations and advisory actions identified in the previous inspection and the review.
• We reviewed external stakeholder and information of concern shared with the Care Quality Commission.

How we carried out the inspection/review

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 site visit.
• Staff questionnaires.
• Feedback from external stakeholders.

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:

• The practice respected patients’ privacy and dignity, and patient confidentiality was maintained throughout the practice.
• The practice did not have clear oversight on the levels of attainment of clinical staff’s safeguarding training.
• The practice did not have oversight on the level of the disclosure and barring checks of all staff members.
• The practice had not ensured that all clinical staff had appropriate knowledge and understanding of consent. Some clinical staff had yet to complete Mental Capacity Act 2005 training.
• Patients expressed difficulty in accessing care and treatment in a timely way.
• Clinical searches completed showed some gaps in following national guidance.
• Verbal complaints raised with the practice were not consistently documented.
• The practice did not always operate effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We found a breach of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

• Implement a clear route for inclusion of clinical staff in policies which have a clinical element.
• Reconcile their safeguard registers to ensure the accuracy of their safeguarding register with the safeguard local authority teams.
• Put in place a consistent staff exit interview process to inform the practice recruitment and retention process.
• Provide appropriate training and support for those staff with additional lead roles, such as infection prevention and control.
• Improve from a single line entry the content in some of the medicine reviews completed by the GPs.
• Amend clinical staff appraisal to include a clinician to enable discussion on competencies and professional development.
• Encourage patients to attend their appointments for the national cervical cancer screening programme.
• Improve involvement of and engagement with the patient population to gain feedback in order to monitor and review the service.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration. Special measures will give people who use the service the reassurance that the care they get should improve.

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